KANSAS PANDEMIC INFLUENZA PREPAREDNESS AND RESPONSE PLAN Version January 2015

Transcription

1 KANSAS PANDEMIC INFLUENZA PREPAREDNESS AND RESPONSE PLAN Version January 2015 Kansas Response Plan Biological Incident Annex Attachment 1

2 Table of Contents Introduction... 4 Situation... 4 Influenza Background... 4 Pandemic Influenza as an Emergency... 5 Planning Assumptions and Considerations... 5 Concept of Operations... 8 Organization of the Kansas Pandemic Influenza Preparedness and Response Plan... 8 INTERPANDEMIC PERIOD Community Resilience and Incident Management Biosurveillance Surge Management Information Management Countermeasures and Mitigation PANDEMIC ALERT PERIOD Community Resilience and Incident Management Biosurveillance Surge Management Information Management Countermeasures and Mitigation PANDEMIC PERIOD Community Resilience and Incident Management Biosurveillance Surge Management Information Management Countermeasures and Mitigation U.S. Government Stage 6: Community Recovery POST PANDEMIC PERIOD Plan Development and Maintenance Authorities and References State Legal Authority January 2015 Page 2

3 Glossary Acronyms and Abbreviations Appendices Appendix A KDHE NIMS Position Title Crosswalk Appendix B Public Health Emergency Activation Levels Appendix C Crosswalk of Activities Appendix D State Preparedness Committees Commission on Emergency Planning and Response Clinical Resource Network Appendix E Coordination List Appendix F Family (Home) Care for Symptomatic Individuals Appendix G Internet Sites Referenced Appendix H HHS Vaccine Priority Recommendations Appendix I Local Pandemic Influenza Response Checklist Appendix J State Pandemic Influenza Checklist Appendix K Community Containment for Disease Tool Box Appendix L Diagnostic Assays during Pandemic Influenza Appendix M Interval Sample Algorithm Appendix N KDHE ILINet Sites January 2015 Page 3

4 Introduction Influenza viruses are unique in their ability to cause sudden illness among humans in all age groups on a global scale. The importance of influenza viruses as biologic threats is due to a number of factors including the high degree of transmissibility, the presence of a vast reservoir of novel variants (primarily aquatic birds) and the unusual properties of the viral genome. The infamous Spanish flu of was responsible for more than 20 million deaths worldwide, primarily among young adults. Mortality rates associated with recent pandemics of 1957 and 1968 were reduced in part by the use of antibiotic therapy for secondary bacterial infections and aggressive supportive care of infected patients. However, these later pandemics were associated with high rates of morbidity and social disruption. Although the 2009 influenza A H1N1 pandemic influenza virus had a low pathogenicity, mortality was reduced in part due to national implementation of community disease mitigation measures developed as part of pandemic influenza planning. The Centers for Disease Control and Prevention (CDC) estimates the economic loss associated with the next severe pandemic will be in the billions of dollars. Experts agree an influenza pandemic is inevitable. To prepare for the next pandemic, the Kansas Department of Health and Environment (KDHE) Bureau of Community Health Systems (BCHS), in cooperation with local and state partners, has developed this Kansas Pandemic Influenza Preparedness and Response Plan, which provides an overview of strategies to reduce pandemic influenza-related morbidity, mortality, and social disruption in the state. Situation Influenza Background Influenza is an illness caused by viruses that infect the respiratory tract of humans. Signs and symptoms of influenza infection include rapid onset of high fever, chills, sore throat, runny nose, severe headache, nonproductive cough, and intense body aches followed by extreme fatigue. Influenza is a highly contagious illness and can be spread easily from one person to another. It is spread through contact with droplets from the nose and throat of an infected person during coughing and sneezing. The period between exposure to the virus and the onset of illness is usually about two days, although it can range from 1-5 days. Patients are most infectious during the 24 hours before the onset of symptoms and for 3-5 days after onset of illness. Influenza is highly contagious and persons who are sub-clinically infected (show no signs of illness) can transmit the virus. Influenza is not an endemic disease, but in the northern hemisphere annual epidemics usually occur from December through April. There are two types of influenza viruses that cause significant disease in humans: type A and type B. Only influenza A has been known to cause pandemics. Influenza A viruses are composed of two major antigenic structures essential to the production of influenza vaccines and the induction of immunity: hemagglutinin (H) and neuraminidase (N). Influenza A viruses are unique because they can infect both humans and animals; most influenza A viruses are considered to be avian in origin. Worldwide avian influenza control efforts are coordinated by the World Organization for Animal Health (OIE). The state animal agency (i.e., Kansas Department of Agriculture, Division of Animal Health (KDA)) would play a role in these efforts. January 2015 Page 4

5 Pandemic Influenza as an Emergency Pandemic influenza is a unique public health emergency. No one knows when the next influenza pandemic will occur. However, when it does occur it will likely be with little warning. Since the novel virus may be identified in any region of the world, experts believe that no more than 1-6 months would pass from the identification of a novel influenza virus to widespread outbreaks in the United States. Outbreaks are expected to occur simultaneously throughout much of the nation, so re-allocation of human and material resources is not a practical option. Historically, influenza pandemics have occurred in waves and it is expected this will happen with future pandemics. A pandemic wave (a time period during a pandemic when increased numbers of people are becoming sick) can last as long as 6-8 weeks. As a result of this, the World Health Organization (WHO) and the CDC have defined phases of a pandemic in order to facilitate coordinated plans. The United States has also established stages of federal government response that correlate with the WHO phases. These actions are described throughout this plan and are summarized on the Flu.gov website ( under the HHS Pandemic Influenza Plan ( In addition, Kansas is continually integrating the use of federally defined planning intervals and stages. Tied to surveillance, this integration will allow for a timelier response at the local and state levels. This trigger system further sensitizes the response infrastructures and ties actions directly to those already linked to the Pandemic Severity Index. Decision process algorithms may be utilized in conjunction with both local and state standard operating guidelines to better orient the state response to a pandemic. Planning Assumptions and Considerations The following are assumptions that provide a basis for preparedness activities pertaining to pandemic influenza: Pandemics may have very mild or very severe morbidity, mortality, and economic impacts to individuals and society. Authorities should be ready with a scalable response system to address this spectrum. This plan intends to address a severe pandemic scenario and allows for such scalable response implementation based upon the specifics of the pandemic. Influenza pandemics are expected but unpredictable and arrive with very little warning. Outbreaks can be expected to occur simultaneously throughout much of the U.S., making shifts in human and material resources that usually occur in response to other disasters untenable. o Localities should be prepared to rely on their own resources to respond. o As with many public health emergencies, the effect of influenza on individual communities will be relatively prolonged (weeks to months) in comparison with other types of disasters. Anticipating a high attack rate associated with severe pandemic influenza viruses, the number of persons affected in the U.S. is expected to be similarly high and it is estimated that: o Up to 200 million people will become infected o Between 38 million and 89 million may be clinically ill January 2015 Page 5

6 o Between 18 million and 42 million may require outpatient care o Between 314,000 and 734,000 may require hospitalization o Between 89,000 and 207,000 may die o The national estimates for pandemic infections, illnesses, outpatient visits, hospitalizations, and deaths are taken from Meltzer MI, Cox NJ, Fukuda K. The economic impact of pandemic influenza in the United States. Emerging Infectious Diseases 1999;5: Available at In Kansas it is estimated that, in a severe pandemic: o Between 229,000 and 535,000 persons may require outpatient care o Between 5,000 and 11,700 may require hospitalization o Between 1,200 and 2,700 individuals may die o Kansas estimates are taken from a software program that uses 2010 census figures to calculate state-specific numbers. Meltzer MI, Shoemaker HA, Kownaski M, Crosby R, FluAid 2.0: A manual to aid state and local-level public health officials plan, prepare and practice for the next influenza pandemic (Beta test version). Centers for Disease Control and Prevention, U.S. Department of Health and Human Services. Though a new model is not available, KDHE anticipates that the current numbers will be higher especially in a severe pandemic. Healthcare workers and other first responders may be at higher risk of exposure and illness than the general population, further straining the healthcare system. Effective prevention and therapeutic measures, including vaccine and antiviral medications, will likely be delayed and in short supply. Widespread illness in the community could increase the likelihood of sudden and potentially significant shortages of personnel in other sectors that provide critical public safety services. Public and private partners have been brought into the planning process and systems for communications among the partners are in place. Pandemic influenza planning will be integrated into all-hazards preparedness activities. Influenza-like illness (ILI) surveillance is already in place. Mass prophylaxis clinic protocols are developed. The following compose the anticipated federal roles in pandemic influenza preparedness and response: Disease surveillance in the U.S. and globally Epidemiological investigation in the U.S. and globally Development and use of diagnostic laboratory tests and reagents Development of reference strains and reagents for vaccines Vaccine evaluation and licensure Determination of populations at highest risk and strategies for national vaccination and antiviral medication use Assessment of measures to decrease transmission (such as travel restrictions, isolation and quarantine) Purchase and deployment of federal cache of antiviral medication and vaccine Evaluation of the efficacy of response measures January 2015 Page 6

7 Deployment of the Commissioned Corps Readiness Force and Epidemic Intelligence Service officers Medical and public health communications to the public and health and medical sector organizations Identification and training of Principal Federal Officers (PFO) and Federal Coordinating Officers (FCO) to work with State Coordinating Officers (SCO) during pandemic response Provision of federal guidance and expectations for exercises The following compose the anticipated state roles in pandemic influenza preparedness and response: Identification of statewide public and private sector partners needed for effective planning and response Development of key components of the pandemic influenza preparedness plan; planning and coordination, situation monitoring and assessment, prevention and containment, health system response, and communications Epidemiologic investigations and analysis statewide Identification of priority groups for vaccination based on federal recommendations Maintenance of influenza surveillance system, and development and implementation of enhancements as appropriate Maintenance and storage of state purchased antiviral medication and equipment cache Logistics planning for distribution of antiviral medications and vaccine Integration of pandemic influenza planning with other planning activities conducted at the local and state levels Coordination with local jurisdictions to ensure development of local plans and guides as outlined by the state plan and provision of resources, such as templates to assist in the planning process Development of data management systems needed to implement components of the plan Participation with local jurisdictions in developing, exercising, and evaluating their plans Coordination with adjoining jurisdictions and states Training state staff on roles and responsibilities identified in this plan Evaluating exercises and developing improvement plans to maximize state response coordination Cooperation with federal partners to enhance laboratory monitoring of seasonal influenza viruses Conducting year-round surveillance activities, seasonal influenza analysis, and testing to detect novel subtypes of influenza viruses Education of laboratory staff on safe handling of specimens suspected to contain novel influenza viruses and surveillance for influenza-like illness among laboratory personnel The following compose the anticipated local roles in pandemic influenza preparedness and response: Identification of local public and private sector partners needed for effective planning and response January 2015 Page 7

8 Coordination with adjoining jurisdictions Maintenance and exercise of the Emergency Support Function (ESF) 8 component of the County Emergency Operations Plan (EOP), the Biological Incident Annex (BIA), and associatied implementation guides including the Mass Dispensing Standard Operating Guide (SOG), Public Information and Communication SOG and other guidance and policy documents, as appropriate Continue to emphasize the importance of annual influenza vaccination and the routine administration of pneumococcal vaccine for recommended risk groups during the preparation phases of the pandemic Administer a system to estimate the number of persons in priority groups for vaccination and deliver vaccine Assure the security of influenza vaccine during storage and delivery when it becomes available Plan for the potential of civil unrest due to resource scarcity Maintain the Public Information and Communication SOG and ensure coordination of information with local emergency management coordinators, hospitals and at-risk populations Maintain media relations at the local Joint Information Center (JIC) Maintain a 24/7 contact list of key health department staff, local partners and media contacts Work with the Kansas Health and Environmental Laboratories (KHEL) to address local laboratory surge capacity issues Train personnel in the management of respiratory specimens during an influenza pandemic Institute surveillance for influenza-like illness among laboratory personnel working with influenza virus Plan for and implement laboratory surge capacity to manage increased numbers of requests for influenza testing Send selected specimens from possible pandemic influenza patients to KHEL Clinical laboratories that receive diagnostic specimens from patients with suspected novel influenza (based on clinical and epidemiologic data) should contact KDHE Concept of Operations Organization of the Kansas Pandemic Influenza Preparedness and Response Plan This plan is organized according to the World Health Organization (WHO) Pandemic Phases along with the corresponding U.S. Government Stages and CDC Intervals. The following functions are described in each applicable phase/stage: community resilience and incident management, biosurveillance, surge management, information management, and countermeasures and mitigation. This plan has been developed in such a manner as to be scalable to the pandemic incident as it presents. While the plan primarily addresses a scenario of a severe pandemic, the activities and functions may be activated at a lower capacity to address more mild pandemics. January 2015 Page 8

9 All state and local governments are required to have an emergency operations plan, which addresses all hazards. However, pandemic influenza is likely to pose unique challenges that may not be addressed in current emergency management plans. To address these challenges, emergency management plans should incorporate a Biological Incident Annex (BIA) maintained by local and state health agencies that include specific pandemic influenza elements. Some of the issues addressed within a BIA include: Medical services and healthcare workers may be overwhelmed during an influenza pandemic, and medical supplies may be insufficient. Healthcare workers may not be able to provide essential care to all patients in need. Unlike the typical disaster, because of increased exposure to the virus, essential community services personnel such as healthcare personnel, law enforcement officers, firefighters, emergency medical technicians and other first responders may be more likely to be affected by influenza than the general public. An influenza pandemic may also pose significant threats to the human infrastructure responsible for critical community services. This threat will be due in part to widespread absenteeism in the workforce. Significant decreases in the workforce could impact distribution of food, home meal deliveries, day care, garbage collection, utilities and other critical services. Physical infrastructure may be threatened or destroyed if there is civil disorder. KDHE-BCHS staff members have developed local SOG templates and state SOGs that address details of implementing local and state response plans, including contact lists for partner organizations and resource owners, step-by-step operational guidelines, job action sheets for key staff and notification procedures. Local health departments have completed the Mass Dispensing SOG, which describes how mass vaccination and pharmaceutical dispensing clinics will be conducted. They have also completed SOGs that describe specific actions regarding community disease containment, public information and continuity of operations. January 2015 Page 9

10 WHO Phases U.S. Government Stages CDC Interval INTERPANDEMIC PERIOD 1 2 No new influenza virus subtypes have been detected in humans. An influenza virus subtype that has caused human infection may be present in animals. If present in animals, the risk of human disease is considered to be low. 0 No new influenza virus subtypes have been detected in humans. However, a circulating animal influenza virus subtype poses a substantial risk of human disease. New domestic animal outbreak in at-risk county Investigation Community Resilience and Incident Management The KDHE Director of the Division of Public Health, who serves as the State Health Officer, or his or her designee, will lead the state response to pandemic influenza or any other infectious disease emergency in Kansas. Local health departments will also develop and implement a structured parallel system of pandemic influenza preparedness. Community Preparedness The KDHE Director of the Division of Public Health has designated a Pandemic Influenza Preparedness Committee (PIPC) to develop this Kansas Pandemic Influenza Preparedness and Response Plan and to provide guidance to local health departments regarding local plan development. The members of the PIPC will advise the KDHE Director of the Division of Public Health on issues related to their specific areas of expertise for implementation of the state s public health response to pandemic influenza. Members of the PIPC are listed in Table 1. Table 1 Pandemic Influenza Preparedness Committee (PIPC) Members Director KDHE Division of Public Health State Epidemiologist Preparedness Director, Bureau of Community Health Systems Director, Bureau of Community Health Systems Director of Homeland Security Operations, Bureau of Community Health Systems Director, KDHE Office of Communications Director, Bureau of Epidemiology and Public Health Informatics Laboratory Response Network Coordinator Director, Kansas Health and Environmental Laboratories (KHEL) Kansas Medical Countermeasures Program Coordinator, Bureau of Community Health Systems Director, Kansas Immunization Program Surveillance Director, Bureau of Epidemiology and Public Health Informatics All of the members of the PIPC are housed within KDHE. Many other subject matter experts within and outside of KDHE are available to provide advice and support to the PIPC. January 2015 Page 10

11 The PIPC will review this Kansas Pandemic Influenza Preparedness and Response Plan at least annually and recommend updates. The BCHS Director of Homeland Security Operations will be responsible for updating the plan document. Activities of the PIPC are briefed at the Kansas Commission on Emergency Planning and Response, which meets quarterly. The Clinical Resource Network, a group of practicing physicians who are available for consultation during a public health emergency, may also review the plan and provide feedback as needed. The agencies represented for each of these committees are listed in Appendix D. The Kansas Division of Emergency Management (KDEM) is responsible for promulgating standards for local emergency planning. Staff from KDHE and KDEM collaborated to develop the standards for Emergency Support Function (ESF) 8 Health and Medical and for the local BIA template. Local pandemic influenza response is described in local BIAs. The Kansas Pandemic Influenza Preparedness and Response Plan is housed within the state BIA as Attachment 1. Kansas has a decentralized system of 117 enhanced centers, which serve as the Public Safety Answering Points (PSAPs) for Kansas communities. To facilitate local preparedness, the U.S. Department of Transportation has released the document Preparing for Pandemic Influenza: Recommendations for Protocol Development for Personnel and Public Safety Answering Points (PSAPs) which may be accessed at The Kansas Highway Patrol (Patrol) has agreed to allow its own agency pandemic preparedness and response plan to be utilized as a guide for local public safety planners. The Patrol has a central communication center that conducts activities similar to PSAPs (with respect to dispatching emergency responders) and may serve as a beneficial guide to local entities. The Kansas Board of Emergency Medical Services (KBEMS) is currently writing EMS pandemic influenza operational procedures that define the role of EMS in preparing for, mitigating and responding to pandemic influenza. This plan will be a part of the overall all hazards response plan which forms the basis of the agency s internal and external operating procedures in a contingency environment for ensuring Emergency Medical Service systems ability to respond to an emergency. A key mission of the agency is to ensure the provision of expedient, effective and efficient assessment, treatment, transport and accountability of casualties of natural or manmade disasters while ensuring employee health and safety. The State of Kansas continues to build relationships with the private sector, including hospitals and other industries. Various outreach measures have occurred, including forums with industry leaders to discuss further cooperation efforts as well as providing pandemic influenza-specific information for industry on websites. BCHS has updated its website to include a section specifically targeting business and industry and preparedness efforts at KDHE will continue to work with KDEM and the U.S. Department of Homeland Security Protective Security Advisor to share information relevant to protecting critical infrastructure, key resources, and industry in general, and to promote preparedness efforts to increase response cooperation and coordination. January 2015 Page 11

12 Emergency Operations Coordination Kansas has adopted the Incident Command System (ICS) and National Incident Management System (NIMS) for responding to disasters and emergencies (Executive Order 05-03). The NIMS was published in March 2004 and the National Response Framework (NRF) became finalized in January Local and state agencies have revised plans to include NIMScompliant activities and to align with the NRF. This is a challenging process that requires crossagency and cross-jurisdictional coordination in order to be successful. KDHE has established the current system of incident management based on the ICS to organize the response to public health and medical emergencies in Kansas. Throughout this plan, ICS titles are used to identify roles and responsibilities for responding to a pandemic influenza incident. Day-to-day position titles are used in the preparation phases of the plan to clearly indicate planning responsibilities. The KDHE utilizes Incident Activation Levels (IALs) to determine and iterate the proper levels of activation of the KDHE Department Operations Center (DOC) and ICS. A chart outlining the IALs is provided in Appendix B. When conditions or criteria suggest a Level 3 activation, which is not expected to occur in United States Government (USG) Stage 0, KDHE will activate its ICS. This process will be further described later in this plan. KDHE has developed job action sheets and training materials for the Command and General Staff roles. Local health departments are required to maintain and update plans and SOGs regarding response to public health emergencies. These plans and SOGs contain specific information regarding mass vaccination clinic activities, communications and treatment center coordination. The local SOG templates can be found on the KDHE public website: Components of this plan and the corresponding SOGs will be exercised at least annually. Evaluations of the exercises will be conducted and improvement plans will be developed in accordance with the Homeland Security Exercise Evaluation Program ( The Public Health and Healthcare Preparedness Capabilities ( ( will be used to evaluate health and medical aspects of the exercises. The recommended updates will be made to this plan and the corresponding SOGs upon completion of after-action reviews. The Kansas Department of Agriculture (KDA) is responsible for food safety regulation in Kansas, and risk based inspections are designated as a Priority 1 Essential Service in the KDA Continuity of Operations (COOP) plan. Staff from a variety of programs outside of food safety may be utilized to conduct inspections and ensure compliance with federal statutes administered by United States Department of Agriculture (USDA), the HHS Food and Drug Administration (FDA) and KDA. The point of contact for food safety issues in the event of a pandemic is the Emergency Management Coordinator, Office of the Secretary, Kansas Department of Agriculture. The KDA COOP plan includes a pandemic as a possible threat. This plan ensures that each position January 2015 Page 12

13 designated as critical will be backed up with at least three trained individuals. Currently, the KDA Legislative Researcher and the KDA Public Information Officer (PIO) serve as backup should the KDA Emergency Management Coordinator be unavailable during a food safety emergency. The KDA also works closely with KDHE Bureau of Epidemiology and Public Health Informatics (BEPHI). The BEPHI will most likely receive initial notification of foodborne illness activity and will be a critical component to an effective response to a food safety emergency during a pandemic or any other time. These responsibilities occur on a day-today basis and are outlined in statute, the Kansas Response Plan, and agency protocols and procedures. The KDA COOP plan ensures that two additional personnel are trained and identified for each position currently charged with essential food safety functions. A just-in-time training program is under development that can be used if more than twice the number of staff would be needed in the event of a pandemic. Food Safety Reporting In all emergencies in Kansas, local entities report problems and request resources through the county Emergency Operations Center (EOC). This process would not change in a pandemic. Issues are first resolved at the local level, and then mutual aid is utilized if available. Problems and resource requests that cannot be handled at the local level are reported to the Response Section in the State EOC (SEOC). Issues with food safety specifically will be tasked to the ESF 11 desk. Strategic Goal Food Safety Operating objectives for the Kansas Department of Agriculture: Ensure all food producers, transporters, retailers and consumers are aware of information and educational resources before, during and after a pandemic. Assist farm-to-fork operators with planning for the human resource challenges that may affect their businesses during a pandemic. Serve as a source of information for stakeholders regarding state and local actions and resources available to producers. Engage in vigorous continuity of operations planning to ensure that the department can continue to provide the necessary services in order to maintain the integrity and safety of the food supply. The KDA Emergency Management Coordinator serves as the coordinator assigned to prepare the state to carry out critical agriculture programs (ESF 11). The operating objectives for this goal are: Ensure that the KDA COOP plans are trained and tested on an annual basis. Ensure that USDA nutrition assistance programs are identified as priority programs within each responsible agency. Ensure that all COOPs relating to ESF 11 include the identification of backup personnel, cross-training, checklists and notification rosters. January 2015 Page 13

14 Ensure that local units of government, the public and agricultural producers are aware of assistance that will and will not be available from the state during a pandemic. Many Kansans depend on nutritional assistance programs. These programs are managed by a variety of governmental and nongovernmental organizations. In the event of a severe pandemic, many people may be unable to report to work and this may have a major impact on the ability to carry out state-administered programs. The KDA Emergency Management Coordinator is working with the various state program managers to develop and expand on alternate models of delivering these services. Agency COOP plans are currently in development and these nutritional assistance programs will be a priority for each agency responsible for implementing these programs. Local guidance will be developed that describes alternate ways to implement nutritional assistance at the local level. Waivers and executive orders will be drafted that may be utilized to streamline some processes in the event of a pandemic. Nutritional assistance program status will be reported on a weekly basis to the ESF 11 desk in the SEOC. If there are problems or needs, program managers will also report these to the ESF 11 desk as they occur. In the event of an agriculture emergency, the producers will notify their local EOC. Animal disease emergencies are reported to the local veterinarian and are reported to the Animal Health Commissioner based on signs and symptoms. Animal disease incidents will be also be coordinated through the SEOC; staff from the Division of Animal Health will respond to support the ESF 11 function. Requests for assistance will be routed to the ESF 11 desk in the SEOC. Community Recovery Agencies of the State of Kansas participate in the Kansas Continuity of Operations (COOP) Committee. Through this committee, the Kansas Department of Administration has produced and released a reference guide to provide technical assistance on human resource topics to State of Kansas executive branch agencies. Executive branch agencies should use the information contained in the guide during the development of their agency-specific COOP plan to ensure the continuity of internal critical services should buildings/facilities and support infrastructure (staff, Information Technology, and business systems) become unusable or unavailable. In the event a COOP emergency is declared in the State of Kansas, individual agency human resource representatives will be the central points of contact for state employees. State agency human resource offices will be required to determine which workers are essential, how payroll will be processed, what leave options will be granted, and how various staffing issues will be addressed. The reference guide provides material for agencies to evaluate against their own current COOP plan. This reference guide provides direction in the following areas: essential functions and staffing, telecommuting, human resource policies, and communication with employees. Community resilience and incident management activities during the Interpandemic Period include: Identifying issues specific to pandemic influenza Meeting with the Commission on Emergency Planning and Response and other emergency planners Ensuring that specific challenges posed by an influenza pandemic are addressed in hospital response plans January 2015 Page 14

15 Reviewing pertinent legal authorities including: o Isolation and quarantine laws o Laws and procedures for closing businesses or schools and suspending public meetings during a declared state of emergency o Medical volunteer licensure and liability o Compensation laws for in-state, out-of-state, and returning retired medical and non-medical volunteers. Conducting and participating in exercises with hospitals, local communities, EMS, industry, volunteer groups, state agencies, federal agencies and private businesses. Incorporating lessons learned from exercises into improvement plans that are tracked and implemented. Community Resilience and Incident Management U.S. Government Stage 0 Director of the Convene state-level task force to review plan and provide input Division of Public Provide direction and leadership to KDHE PIPC Health, KDHE Work with KDHE Attorney to review legal authorities Medical Identify warehouse space to be used for antiviral and vaccine Countermeasures storage and distribution Coordinator, Train and exercise the distribution plans KDHE-BCHS Operations Ensure the KDHE Department Operations Center is functional Specialist, KDHE- Track NIMS compliance of plans and training of staff at KDHE BCHS Director of Coordinate distribution of pandemic influenza related planning Homeland Security information to critical infrastructure with Kansas Division of Operations, Emergency Management (KDEM) and U.S. Department of KDHE-BCHS Homeland Security (DHS) Protective Security Advisor Revise this plan on an annual basis (January) Work with state and local agencies to ensure all are aware of various roles and responsibilities identified in this plan and the Kansas Response Plan (KRP) Director, KDHE- Lead the KDHE Continuity of Operations Planning group with the BCHS KDA assistance of the BCHS Director of Homeland Security Operations Ensure all food producers, transporters, retailers and consumers are aware of information and educational resources before, during, and after a pandemic Assist farm-to-fork operators with planning for the human resource challenges that may affect their businesses during a pandemic Serve as a source of information for stakeholders regarding local and state actions and resources available to producers Engage in vigorous continuity of operations planning to ensure that KDA can continue to provide the services necessary to maintain the integrity and safety of the food supply January 2015 Page 15

16 Ensure that the KDA COOPs are trained and tested on an annual basis Ensure that USDA nutrition assistance programs are identified as priority programs within each responsible agency Ensure that all COOPs relating to ESF 11 include the identification of backup personnel, cross-training, checklists and notification rosters Ensure that local units of government, the public and agricultural producers are aware of what assistance will and will not be available from the state in a pandemic All local and state Continue continuity of operations planning efforts including agencies training staff and exercising of COOPs KBEMS Develop local EMS planning guidelines and templates Biosurveillance Influenza viruses have constantly changing antigenic properties. Surveillance for pandemic influenza must include both laboratory surveillance, in which influenza viruses are isolated for antigenic and genetic analysis, and disease surveillance, in which the epidemiologic features and clinical impact of new variants are assessed. The goals of influenza surveillance are to detect the earliest appearance of a novel influenza virus in Kansas and to describe the epidemiologic features of novel virus circulation. Since most influenza A viruses are avian in origin, it is essential that KDHE work with Kansas Department of Agriculture and USDA in monitoring circulating animal viruses, especially highly pathogenic avian influenza. KDA has developed a plan to cull poultry in response to detection of highly pathogenic avian influenza. Plans include the provision of personal protective equipment (PPE) and prophylaxis of workers at risk for exposure to the viruses. KDHE will work with KDA to ensure that workers who have been exposed and become symptomatic are treated, to decrease the risk of producing a pandemic strain of influenza by re-assortment of virus. Public Health Surveillance and Epidemiological Investigation The BEPHI, in cooperation with the Kansas Health and Environmental Laboratories (KHEL), maintains Kansas involvement in year-round national influenza surveillance coordinated by the CDC. The BEPHI and KHEL assume primary responsibility for implementing and coordinating virologic morbidity and mortality surveillance components in Kansas and compliance with future recommendations for surveillance enhancement. Current national influenza surveillance activities include: Virologic surveillance: Approximately 85 U.S. World Health Organization (WHO) Collaborating Laboratories and 60 National Respiratory and Enteric Virus Surveillance System (NREVSS) laboratories located throughout the United States participate in virologic surveillance for influenza. All state public health laboratories participate as U.S. WHO collaborating laboratories. Each week the WHO collaborating laboratories report the number of clinical specimens tested for influenza and the number of positive results by virus type (A or B); most January 2015 Page 16

17 also report influenza A subtype (H1 or H3). A subset of the influenza viruses collected by U.S. WHO collaborating laboratories are sent to CDC for further characterization, including gene sequencing, antiviral resistance testing and antigenic characterization. Surveillance for influenza-like illness (ILI): Approximately 2,700 outpatient clinics in all 50 states participate in the U.S. Outpatient Influenza-like Illness Surveillance Network (ILINet). ILINet providers regularly report the number of patient visits for ILI by age group and the total number of patient visits each week during the normal influenza season. Kansas has approximately 40 ILINet sites. These data are used to calculate and track the percentage of outpatient visits due to influenza-like illness. In addition, Kansas will be utilizing BioSense to monitor ILI as chief complaint data in participating hospitals. Surveillance for influenza and pneumonia deaths: The vital statistics offices of 122 U.S. cities report each week the total number of death certificates processed and the number of those for which pneumonia or influenza was listed as the underlying or contributing cause of death by age group. The percentage of deaths due to pneumonia and influenza (P&I) are compared with a seasonal baseline and epidemic threshold value calculated for each week. State and territorial epidemiologists assess influenza activity levels each week and report it as widespread, regional, local, sporadic, or no activity to the CDC. During the Interpandemic Period, KDHE will maintain Kansas current influenza surveillance activities, which include: An ILINet provider program with at least the minimum number of healthcare providers (1 per 250,000 persons) that report their weekly data to KDHE or directly to CDC via the Internet year-round. These providers are encouraged to send specimens collected from patients with ILI at the beginning, middle and end of the normal season to the state laboratory for viral culture at no charge to the provider or patient. A map of counties with ILINet surveillance sites can be found in Attachment N. A disease reporting hotline that is available and is staffed at all times by an epidemiologist, including nights and weekends at Information on the Kansas Board of Healing Arts list of physicians. The Kansas Health Alert Network system. An active State Influenza Surveillance Coordinator in BEPHI who: o Monitors ILINet provider data weekly for completeness and/or errors. o Provides feedback and maintains contact with ILINet providers weekly to encourage reporting and follow-up on unusual reports. o Contributes to state pandemic planning issues and activities. o Maintains a strong working relationship with the KHEL. o Encourages ILINet providers to submit specimens for viral culture to the state laboratory. o Conducts a weekly assessment of overall influenza activity level in the state during the normal flu season and reports the data to the CDC. January 2015 Page 17

18 Kansas uses WebEOC, a Web-based system to manage information and resource requests. Hospital bed availability and other emergency related data are collected in EMResource, which can collect the following statewide data: Available (or needed) staffed beds (specifies adult or pediatric): o ICU/CCU beds o Medical beds o Emergency Department (monitored and unmonitored) Available number of ventilators Available negative-pressure air isolation rooms Number of healthcare professionals affected Morgue capacity Available or needed medical supplies, equipment, and personal isolation equipment Number of hospitals on Emergency Department Diversion Number of patients waiting for inpatient beds (to include average wait time) The electronic screens used to collect this data will be based on forms that will be available in paper format if the Internet-based system fails. Planners are currently working with vendors to integrate WebEOC and EMResource to reduce the need for data to be entered multiple times. KDHE currently has a secure Web-based death certificate registration system that was enhanced as of July It is used by funeral directors and physicians across the state. Funeral directors enter the demographic information of the deceased. Physicians who use the web-based system complete the cause of death electronically and apply an electronic signature. Physicians who do not use the system complete the cause of death by hand and KDHE Office of Vital Statistics (OVS) staff members enter the cause of death upon submission by the local funeral director. The system will be made available to Infectious Disease Epidemiology and Response (IDER), the Bureau of Community Health Systems (BCHS), and OVS staff regarding deaths from specific causes, such as influenza or pneumonia. In the event that the electronic death reporting system is not operational, influenza-associated deaths will be tabulated manually, using traditional, paperbased methods. Epidemiology staff may utilize bridged estimates from the National Center for Health Statistics to calculate estimated rates of influenza-associated hospitalization. In the event of a suspect or confirmed case of pathogenic avian influenza, the Kansas Animal Health Commissioner will contact the State Epidemiologist or designee directly or via the Epidemiology Hotline, in addition to contacting the Adjutant General s Department via . This connection between the Animal Health Commissioner and KDHE seeks to maintain a continuous and coordinated connection between animal and human health surveillance systems. During this period, KDHE, KBEMS and PSAP representatives will discuss the utility of managing and collecting patient and system data for pandemic influenza surveillance. If developed, an EMS and data collection and reporting system could become an enhanced component of a comprehensive influenza surveillance system. This collaborative effort may also address and define EMS policies, procedures and legal authorities for sharing EMS and data with public health agencies as part of the comprehensive surveillance system and address any legal and technological barriers to participating in the disease surveillance process. The January 2015 Page 18

19 system should include a mechanism for rapid modification of data elements and reporting mechanisms based upon updated information on an emerging pathogen (e.g., during the SARS epidemic, questions pertaining to foreign travel were pertinent). Improved situational awareness through information sharing regarding both patients and resources will enable better management of assets during a pandemic and provide for real time epidemiological analysis. KDHE will utilize the Kansas Health Alert Network (KS-HAN) to communicate relevant pandemic influenza information to health and medical providers. The need for a statewide patient tracking system continues to be demonstrated through many emergency incidents. KDHE and the state s Regional Homeland Security Councils continue to work on a patient tracking system that can be utilized at all levels of the medical system to track an individual from first contact with professional medical care through eventual dismissal from care. As part of this effort and as identified in the 2009 Kansas Homeland Security Strategy, KDHE has formed a multi-disciplinary, multi-agency work group to develop a statewide patient tracking system and recommend minimum requirements for electronic applications to support that statewide system. An initial phase of data collection software and hardware is being disseminated to EMS providers throughout the state (along with training in the use of the software) to facilitate acquisition of patient data and its documentation. Information acquired can be used for patient care report generation, individual system analysis and when submitted to KBEMS, specific casualty information such as monitoring of injuries and patient dispositions. Additional funding has been available from KBEMS to augment or enhance capabilities locally. Public Health Laboratory Testing The Kansas Health and Environmental Laboratories (KHEL) play a pivotal role in the detection and identification of influenza viruses. To promote a complete influenza surveillance system, KDHE will maintain: A state public health laboratory that: o Continues to perform real time polymerase chain reaction RT-PCR analysis while providing guidance and interpretation on the increasing use of rapid influenza diagnostic tests in private and public healthcare settings. o Isolates and subtypes influenza viruses during the influenza season. o Maintains the capability to isolate and sub-type influenza viruses year-round and submits isolates to CDC for antiviral resistance analysis. o Transmits influenza data (positives and negatives) electronically to CDC via the CDC/WHO Influenza Surveillance System Reporting website (a secured site). o Provides regular updates on respiratory specimen testing status to the Influenza Coordinator throughout the influenza season. o Conducts RT-PCR testing for novel subtypes of influenza viruses within Biosafety Level 2 (BSL-2) conditions. o In order to facilitate control and management of local outbreaks, ensures prompt reporting of unusual or novel influenza isolates to: BEPHI, via Epidemiology Hotline ( ). LRN Results Messenger for confirmed A/H5 strain. CDC/WHO Influenza Surveillance System Reporting website. January 2015 Page 19

20 o Submits increased numbers of influenza isolates as requested to CDC for enhanced monitoring for antiviral resistance. o Is actively involved in contingency planning for surge capacity (staffing and reporting) and safety issues. Implements enhanced cross-training of existing laboratory staff in RT- PCR methods. Educates clinical laboratorians on the safety and handling of specimens suspected to contain novel influenza viruses. Institutes an influenza vaccination policy for influenza-like illness among laboratory personnel. To protect the health of laboratory workers during a pandemic, public health, clinical, and hospital laboratories should maintain enhanced safety practices. These include: Conducting laboratory procedures under appropriate biocontainment conditions. o Commercial antigen detection testing for influenza should be conducted using BioSafety Level 2 (BSL-2) work practices. o If new or re-emergent human influenza strains with pandemic potential are suspected, laboratories should establish separate BSL-2 containment conditions utilizing BioSafety Level -3 (BSL-3) components, such as enhanced personal protective equipment as recommended by CDC, before RT-PCR testing. As a consequence of the danger that highly pathogenic avian influenza (HPAI) strains present to the U.S. agricultural industry, USDA regulations require that HPAI strains such as H5N1 (which are classified as select agents) must be cultured using BSL-3 biocontainment conditions with enhancements. Strongly encouraging routine vaccination of all eligible laboratory personnel who are exposed to specimens from patients with respiratory infections. Staffing and training laboratories for increased staffing needs. o Cross-training personnel during the regular influenza season in the use of rapid diagnostic tests and RT-PCR protocols and in reporting results through existing surveillance systems. o Recruiting and training temporary staff for employment during a pandemic. Supplies and equipment. o Laboratories are likely to require additional diagnostic supplies and equipment to process large numbers of samples during the initial stages of a pandemic. Some preparedness strategies include: Establishing the current level of diagnostic supplies, including personal protective equipment for laboratorians (e.g., gloves, masks). Assessing anticipated equipment and supply needs, and determining a trigger point for ordering extra resources. Specimen management. o State and local health departments should inform and educate public health staff (including laboratorians), local physicians, and hospital workers on safe and effective methods for specimen collection and management, making use of the January 2015 Page 20

21 guidelines detailed on KHEL s website, packaging and shipping section, under virus shipper guide ( o Procedures for specimen collection, handling, and shipping during a pandemic will be the same as those used for seasonal disease surveillance. However, laboratory staff should anticipate shipping of much larger numbers of specimens in a very short time, especially during the early stages of a pandemic. Biosurveillance U.S. Government Stage 0 Influenza Maintain the ILINet surveillance program with providers Surveillance Maintain a strong working relationship with the KHEL Coordinator, KDHE- Participate in CDC training regarding surveillance and adverse BEPHI events reporting Operations Develop boards in WebEOC to interface with EMResource and to Specialist, KDHE- track bed availability and other scarce resources BCHS KDHE-KHEL Continue to isolate and sub-type influenza viruses year round including reporting during influenza season to CDC KBEMS Continue development of the statewide patient care report system Surveillance Coordinator, KDHE- BEPHI for use by local EMS agencies Development of a secure system for managing and collecting patient and system data Development of a just-in-time training for use of surveillance system and associated tools Surge Management Emergency response, including maintenance of critical services and surge capacity issues in the healthcare system, is addressed in the state, local, and medical facility response plans and SOGs. Medical Surge There are 128 community hospitals in Kansas and the staffed beds in these facilities range from 10 to 1,451. The average daily census indicates that there are approximately 5,000 available beds in Kansas on any given day. It is estimated that during a pandemic influenza event, approximately 5,000 to 10,000 beds would be needed to provide care for influenza patients. Hospitals in Kansas use a regional planning process to prepare for an increase in acutely ill patients. The state is divided into seven regions and each region has designated a regional planning hospital. The regional plans for increasing available bed capacity at each hospital to accommodate a regional surge of 500 acutely ill infectious patients per 1 million population over a short period of time includes the following steps: Hospitals will cancel non-emergency surgeries and other elective procedures. Hospitals will discharge non-infected patients to other acute care facilities out of the affected geographical area, or to long-term care or home care while assuring that the level of care required by these patients can be met. January 2015 Page 21

22 Hospitals will transfer patients to other hospitals in the region with available beds. Hospitals may need to send patients to several other hospitals depending on bed availability. Hospitals will start by transferring patients to hospitals in nearby counties, then to other hospitals in the region. If all hospital beds in the region are at capacity, then hospitals will transfer patients to hospitals in other regions. Finally, if hospitals in other regions are full, the hospital will send patients to alternate locations based upon their partnerships (long term care facilities, schools, etc.). Hospital and county emergency planners have identified and continue to identify alternate care sites. KDHE BCHS has developed a template alternate care site plan that may be utilized to assist community planners. The template plan is located at For an alternate care site to be successful, the entire community and all agencies must work together bringing their own strengths and available resources to bear. Alternate care sites will likely be considered the option of last resort, so all health and medical partners in the community should be engaged in pre-pandemic planning. For example, home healthcare agencies will likely play an important role, given the potentially high number of ill persons. In addition, during a severe pandemic it is expected that family members will likely need to provide care to family members that are unable to be hospitalized. Instructions for home (family) care can be found in Appendix F. Healthcare and hospital personnel will also need to stay informed related to the best practices for infection control for pandemic influenza from the CDC. Those guides may be located In planning for an influenza pandemic, it must be recognized that persons with medical conditions unrelated to influenza will continue to require emergency, acute and chronic care. Alterations to an EMS system s practices during an influenza pandemic will likely impact all EMS patients, regardless of the nature of their illness. Planners should consider modifying PSAP call-taker and dispatch protocols and developing pandemic-specific pre-hospital triage and treatment protocols. It is important to keep the EMS system functioning as effectively as possible and to deliver optimal care to both these patients (e.g. motor vehicle crashes and cardiac events) as well as to patients with influenza related symptoms. Illness and absenteeism during a pandemic may impact an EMS agency s ability to satisfy demand for services. The most serious challenge that the medical system (including hospitals and EMS) will likely face during an influenza pandemic is to keep operations functioning despite increases in call volume, workforce shortages and absenteeism, supply chain disruptions and other threats to continued operations. The foundation of a viable COOP program is the development and documentation of a COOP plan that provides for the continued performance of an organization s essential functions under all circumstances. Agencies should continue to develop, refine and test their COOP plans based on guidance from federal, state and local government. COOP plans should be coordinated with emergency management agencies. Pre-established delegations of authority are vital to ensuring that all organizational personnel know who has the authority to make key decisions in a COOP situation. An order of succession is essential to an organization s COOP. Personnel should know who has authority and responsibility if the leadership is incapacitated or unavailable. COOP plans should address workforce health protection. Health agencies should January 2015 Page 22

23 establish policies for flexible worksite (e.g. telecommuting) and flexible work hours (e.g. staggered shifts) whenever possible. Agencies should establish policies for employee compensation and sick-leave absences unique to a pandemic (e.g. non-punitive liberal leave). Volunteer Management Healthcare and pre-hospital systems should consider a variety of mechanisms to augment their workforce including: Mechanisms for temporary licensure of medical or EMS providers from other jurisdictions Innovative mechanisms to rapidly recruit, train and license new providers Consider non-traditional system configurations and alternate staffing configurations Utilization of retired EMS and healthcare personnel Coordination with local Medical Reserve Corps (MRC) Community Emergency Response Teams (CERT), or cross staffing between EMS, healthcare and other sectors Proactively determine competencies and bridge courses from other professions and levels of EMS licensure Temporary modification of licensure and credentialing procedures to meet the urgent needs of the situation while assuring public health and safety Engaging temporary workers, contractors and recent retirees, and/or cross-training the existing workforce Support telecommuting when feasible. Surge Management U.S. Government Stage 0 Director of the Continue to engage physicians and healthcare providers in the Division of Public planning and preparedness process Health, KDHE Convene workgroups to make recommendations regarding prioritization of scarce medical resources Continue to update individual hospital plans regarding medical surge, evacuation, transport and isolation precautions Kansas hospitals Update EMResource daily with bed information, participate in Kansas Hospital Bed Availability (HAvBED) system drills and exercises Identify and coordinate planning with community partners of alternate care sites that may be used in the event of a pandemic Ensure that state antiviral cache is stored in accordance with Medical manufacturers recommendations Countermeasures Continue to monitor federal guidance to ensure appropriate Coordinator, KDHE- planning for the use of the federally subsidized antiviral caches BCHS All healthcare and Develop and test COOP plans and procedures pre-hospital agencies January 2015 Page 23

24 Information Management In an emergency, accurate, consistent and timely messages are key in notifying and educating the public, notifying and facilitating movement of emergency staff to their assigned duties and stations, and in activating the emergency plan as intended. The following delineates communication-related issues that pertain to pandemic influenza. Assuring adequate communication systems will be a joint responsibility of federal, state and local agencies. During a pandemic, the public will likely encounter some unreliable and possibly false information in the media and on the Internet. KDHE and local health departments will communicate accurate, reliable information regarding the influenza pandemic. Mechanisms for communication with the public will vary depending on the phase of the pandemic and its impact on Kansas communities. KDHE will continually strive to communicate with all essential partners. Emergency Public Information and Warning CDC will make a number of materials available before and during an influenza pandemic, including: Basic communication materials (such as question and answer sheets and fact sheets) on influenza, influenza vaccine, antiviral medication and other relevant topics in various languages. General preventive measures such as dos and don ts for the general public. Information and guidelines for healthcare providers. Training modules (Web-based, printed and video). Presentations, slide sets, videos and documentaries. Symposia on surveillance, treatment and prophylaxis. Due to anticipated shortages of vaccine and antiviral medication, messages to inform the population about availability, the rationale for priority groups and measures to be taken will be critical. Other important topics include: Basic information about influenza (including prevention, symptoms and transmission). Information about the course of the pandemic (contagiousness, geographic spread, confirmed and estimated case counts and deaths). Information about which symptoms should prompt seeking medical attention and which symptoms should be managed at home. Information about the availability and proper use of vaccines and antiviral medications. Information about school and business closures and suspended public meetings. Information about travel restrictions as well as isolation and quarantine laws. Information Sharing The KDHE Director of the Division of Public Health has convened the Kansas Pandemic Influenza Task Force to ensure that the medical community is made aware of issues related to pandemic influenza. This task force consists of representatives from public health, the state medical society, the nurses association, the pharmacy association, the hospital association, emergency management, corrections, long-term care representatives, and a variety of other stakeholders (See Attachment D for a list of agencies represented). The committee will address such issues as education for the medical community and the public, planning for pandemic at a January 2015 Page 24

25 community level, and medical surge capacity. During this Interpandemic Period, KDHE is coordinating with local and state Chambers of Commerce to ensure that private businesses and workers are informed about pandemic preparedness, prevention and response activities. This information will also be communicated to state government workers across State of Kansas. The Kansas Department of Agriculture (KDA) is a regulatory agency that is charged by law to ensure a safe food supply, responsible and judicious use of pesticides and nutrients, the protection of Kansas natural and cultivated plants, integrity of weighing and measuring devices in commerce, and that the state s waters are put to beneficial use. Communication with all of the regulated entities occurs on a regular basis. Regulated entities include: meat and poultry processors, grocery and convenience stores, restaurants, food manufacturers, food wholesalers, lodging facilities, wineries, bottlers, dairies, milk haulers, fuel stations, grain elevators, pesticide and fertilizer products, pesticide applicators, feed manufacturers, seed dealers, nurseries, feedlots, and plant wholesalers and retailers. The department also is responsible for managing the state s water resources and for regulating manmade activities that impact the flow of rivers and streams. In the event of a pandemic, KDA will share information provided by KDHE with all appropriate stakeholders. The process for reporting status of facilities and resource requests will also be clearly communicated to stakeholders during all phases of the pandemic. KDA also coordinates with the Kansas Department of Wildlife, Parks and Tourism (KDWPT) regarding animal health (domestic and wild). The Kansas State Department of Education (KSDE) communicates with local educational agencies in the event of an emergency using the KSDE website, listervs, automated phone trees, fax, print media and commercial broadcasts. This communication takes place primarily with public schools and school districts, though some private schools can be contacted through the automated phone tree and listervs. KSDE s Communications & Recognition Team handles message creation and distribution, ensuing consistency and quality control of messages. The Director of KSDE s Communications & Recognition Team is the state-level education spokesperson for media relations and communication with local educational agencies. KDHE will: Maintain KS-HAN to effectively communicate with public health officials, healthcare professionals and other target audiences. Establish lines of communication and define KDHE staff roles and responsibilities clearly to facilitate the best possible communication with partners. Regularly distribute informational updates to all appropriate partners. In collaboration with state-level partners, provide Community Mitigation guidance to facilities such as day cares, K-12 schools, colleges, universities, long-term care facilities and correctional institutions. Maintain the list of media spokespersons and contact information from each state agency. Coordinate with KDEM to provide information to the media via the state JIC when activated. Develop an operational plan to distribute communications and educational messages to the public. January 2015 Page 25

26 Educate public health officials, elected officials and the media about what information will and will not be available during a pandemic. Review CDC materials and adapt and revise as needed. Information Management U.S. Government Stage 0 Director of the Review materials developed by staff to ensure medical accuracy Division of Public Provide informational presentations to stakeholders Health, KDHE Director of Communications, KDHE KS-HAN Administrator, KDHE-BCHS Exercise and Training Coordinator, KDHE- BCHS Operations staff, KDHE-BCHS KDA KSDE Develop educational materials to be distributed in later stages. Materials include: (1) Family (Home) care of symptomatic individuals, when to go to the hospital, infection control in the home, when to call the hotline (2) Information for businesses: Social distancing recommendations in the workplace, how to manage increased absenteeism. (3) Information regarding handling of human remains, hotline numbers, process for burial, death certificates, what to expect Provide training and resources to local health and medical staff who may be called to speak to the media during a pandemic Monitor the KDHE website to ensure that preparedness and influenza information is up-to-date and accurate Prepare message maps for anticipated questions Continue to update the KDHE Public Information and Communication (PIC) Plan Establish a mechanism to activate hotline capabilities during a pandemic response In conjunction with the BCHS Exercise and Training Coordinator, develop just-in-time training for hotline operators Assist KDHE Director of Communications with development and implementation of systems to facilitate communications with the public and key stakeholders Conduct monthly tests of KS-HAN Develop and conduct exercises to test the state s ability to use the systems developed to enhance communications. Monitor progress on improvement plans and retest capabilities and tasks that are not completed to standard Work with the BCHS Exercise and Training Coordinator to implement actions identified in improvement plans as a result of exercise activities Maintain communication avenues with regulated entities for the provision of emergency information Maintain communication systems with school districts and private schools January 2015 Page 26

27 Communications & Recognition Team, KSDE Prepare message maps for anticipated questions regarding school dismissal and other pandemic influenza educational system related questions Countermeasures and Mitigation There are three actions that can be taken to prevent and contain outbreaks of pandemic influenza: nonpharmaceutical interventions (NPI) use of antiviral medication, and vaccination. Medical Countermeasure Dispensing During the initial months of an influenza pandemic, no vaccine will be available because it is not possible to produce a vaccine without knowing the characteristics of the novel virus. Unlike annual production of influenza vaccine, wherein strains are selected in the spring leading to vaccine distribution in the late summer, a pandemic strain could be detected at any time. Current manufacturing procedures require at least 6-8 months before large amounts of vaccine are available for distribution. Nevertheless, vaccine administration will likely become an important preventive strategy during the next influenza pandemic, once an effective vaccine is developed. Contrasts between delivery of pandemic vaccine and the annual influenza vaccine include the following: The target population will be modified, possibly to include sub-populations most likely to acquire or transmit influenza or most likely to develop complications. It is impossible to predict how quickly the novel virus would arrive in the U.S. On account of the minimum 6-8 month period to produce a vaccine, it is anticipated that demand for vaccine will be greater than the supply early in the course of the pandemic. It is also possible that no vaccine will be available. Once vaccine is available, it will need to be distributed as quickly as possible. Immunologic responses following initial vaccination of serologically negative individuals is poor and represents a priming of the immune system. The emergence of a pandemic strain with new hemagglutinin and or neuraminidase antigens will likely require a second (booster) dose of vaccine to be administered 2-4 weeks after the first dose is given. A final decision regarding the degree of federal vaccine purchase during a pandemic may not be made until the pandemic vaccine is being produced. The Kansas plan for delivery and administration of vaccine addresses many possible scenarios, including complete federal purchase and distribution to states, partial federal purchase with distribution to states, and minimal federal purchase (similar to the current annual influenza vaccination program). Currently influenza vaccine is primarily administered through the private sector. Coordination with and education of the private sector is a key aspect of local and state-level pandemic influenza planning. During the H1N1 pandemic, KDHE utilized a public-private partnership model for vaccine administration. Through this partnership, KDHE served as the centralized vaccine ordering point for all pandemic H1N1 vaccine. Private providers registered via a KDHE website their interest in providing vaccine. Those interested parties were then vetted by their local health department and entered into the system. To order vaccine, those private providers would submit an order through the local health department that would prioritize, validate and approve the order. All county orders were then submitted by KDHE January 2015 Page 27

28 utilizing the normal business mechanisms of CDC for the vaccine program. Vaccine was then delivered to and administered by the private provider who then reported the doses administered using the Kansas Countermeasures Response Administration (KS-CRA) system. This system maximized those normal business practices of many entities and proved to be relatively easy to use. This or a similar model may be utilized during the next pandemic. Due to a relative shortage of vaccine that is expected early in the pandemic, vaccine recipients will be prioritized. Recommendations for priority groups will be made at the national level, which will be adapted by KDHE. The CDC released guidance on allocating and targeting of pandemic influenza vaccine in July The Federal Vaccine Priority Recommendations are provided as Appendix I. KDHE s Vaccine Prioritization Workgroup continues to review the federal recommendations related to adopting a plan specific to Kansas. Eventually, it is assumed that sufficient vaccine will be available for mass vaccination of the total population. Local health departments have conducted detailed planning activities that have culminated in the creation of the local Mass Dispensing SOG. This guide explains the specific operations of large-scale clinic management and how to develop various functions of mass dispensing related to smallpox, chemo-prophylaxis, and influenza vaccination clinics. The KDHE Adverse Events Coordinator is actively involved in vaccination planning. KDHE is upgrading its immunization registration, inventory management and smallpox vaccination reporting infrastructures. KDHE will utilize the Vaccine Adverse Event Reporting System (VAERS) to monitor adverse events related to the pandemic influenza vaccine. An influenza pandemic may pose significant threats to the human infrastructure responsible for critical community services due to widespread absenteeism and exhaustion in the workforce. Examples include highly specialized workers in the public safety, utility, transportation and food service industries, and will likely vary from jurisdiction to jurisdiction. The CDC has issued guidelines recommending certain priority groups to receive vaccine and antiviral medication. The CDC priority group recommendations can be found in Appendix I. The KDHE Vaccine Prioritization and Antiviral Distribution work groups are reviewing the guidelines and will make recommendations in the next iteration of this plan. Based on the severity, target population, ACIP recommendations and availability of vaccine it is anticipated that the vaccine will be targeted to those at higher risk of severe morbidity or mortality issues irrespective of employment. However, some planning scenarios have a mixture of prioritization groups that include employment classes and medically at-risk criteria. The success of the pandemic influenza vaccination program will be determined in large part by the strength of local and state vaccination programs during the Interpandemic Period for three main reasons: (1) increased acceptance of and public confidence in the vaccine; (2) stimulation of vaccine production by manufacturers to meet demand; and (3) strengthening of distribution channels. During the Interpandemic Period, efforts to increase pneumococcal polysaccharide vaccination (which can reduce the incidence of invasive pneumococcal disease secondary to influenza) is recommended and emphasized. Since large-scale pneumococcal vaccination may not be feasible January 2015 Page 28

29 once a pandemic alert has occurred, the Interpandemic Period is the ideal time to deliver this preventive measure. Medical Materiel Management and Distribution Vaccine will not be available when the novel influenza virus first affects communities. Therefore, the role of antiviral medications becomes especially significant during this period for the control of influenza. Existing production capacity for influenza antiviral medication is less than would be needed to provide prophylaxis or treatment for the entire population and the current supply of antiviral medication stored within the federal cache is limited to enough courses to treat 15 percent of the U.S. population. Also, Kansas has purchased enough antiviral medication to treat an additional 10 percent of the state s population. Combined, there are enough antiviral courses for one course of treatment for 25 percent of Kansans. Current federal guidance requires that antiviral medications in this program are to be used for treatment only. Typically, therapy is effective at decreasing severe complications and reducing hospitalizations only if offered within two days of developing symptoms. Distribution of antiviral medications for therapy will be challenging, given the limited amount available, the large number of points of care and the need to initiate the course of treatment within 48 hours of onset of symptoms in order for the medications to be effective. Antiviral medication from the SNS will be distributed to points of care utilizing the distribution system that is detailed in the Kansas SNS Plan. The KDHE Director of the Division of Public Health will determine whether controls for dispensing (such as positive rapid test) will be required. He or she will also provide guidelines on appropriate use of antiviral medications that are distributed. Antiviral resistance characteristics of the pandemic influenza virus strain will be a major factor in such determinations. Public education will be very important given the scarcity of this resource. Prioritizing within priority groups will be necessary given the limited supply. For antiviral medication purchased with public funds, the state will be responsible for local distribution of the antiviral medication in collaboration with the private sector. As with vaccine, it will be critical to clearly communicate with the public about the rationale for priority groups. Coordination with and education of the private sector is a key component of the plan. The Kansas Countermeasure Response Administration (KS-CRA) system will be utilized by all providers who dispense state or federal antiviral medication resources. Tracking activity in KS-CRA may vary depending on provider type, but a thorough accounting of all medication doses from state and federal caches will be required. During the Interpandemic period, KDHE will continue to develop the KS-CRA system. Additional information regarding KS-CRA may be found at Current federal guidance requires that antiviral medications provided through the federal cache are to be used for treatment only, not prophylaxis. Non-Pharmaceutical Interventions The CDC has recommended an early, targeted, layered use of non-pharmaceutical interventions as a key strategy to mitigate the effects of a pandemic on a community. The guidance document January 2015 Page 29

30 can be found on the website. KDHE staff prepared a guidance document for local community planners that linked the CDC guidance to the Community Containment for Disease Tool Box that was provided to local health department planners in This guidance document is located at The interventions recommended by the CDC are: Isolation and treatment (as appropriate) with antiviral medication of all persons with confirmed or probable pandemic influenza Voluntary home quarantine of members of households with confirmed or probable influenza cases Pre-emptive, coordinated school dismissals during a severe influenza pandemic o Guide to Community Preventive Services. Emergency preparedness and response: school dismissals to reduce transmission of pandemic influenza. Last updated: 08/2012. Use of social distancing measures in the workplace and in the community Kansas planners recognize that community containment measures must be implemented at the local level. Local health department personnel worked with their community partners to develop guides and processes that were specific to their communities. These SOGs were exercised in 2006 and communities are now in the process of refining their plans and procedures based on improvement plans that were written as a part of the exercise evaluation process. This comprehensive community mitigation strategy is intended to slow the spread of pandemic influenza, ultimately saving lives and reducing demand on healthcare resources, including EMS. KDHE has worked closely with the Kansas State Department of Education (KSDE) and the Kansas Association of School Boards (KASB) to develop a Pandemic Action Kit for local school districts. The kit contains sample parent letters, checklists for schools, media material, fact sheets, guidance documents, and other useful materials. KSDE anticipates families will need to focus on basic, immediate physical and emotional needs during times of crisis, rather than on educational needs. Once a decision is made to dismiss a school, recommended actions for school districts to take might include: 1. Students should take library books, textbooks, journals, content notebooks, etc., for use during the time of a school closing. 2. Distributing course materials via the Internet is an option for an extended period of time. Each district could post items in the content areas by grade level on their website. KSDE resources could also be accessed at During a time of extended school closing, areas may be operating with limited availability of many things. Educational content could be made available through the state website and/or respective district websites. Responder Safety and Health Health and medical sector organizations will maintain appropriate respiratory protection programs in an effort to protect employees from infectious diseases. Organizations will continue to maintain appropriate stocks of respiratory and other infection control equipment. Appropriate January 2015 Page 30

31 training, fit testing and vaccinations should be provided to employees to promote a ready workforce. Countermeasures and Mitigation U.S. Government Stage 0 Lead work group efforts to define and recommend containment activities to local communities Enhance influenza vaccination coverage levels in traditional highrisk groups, especially subgroups in which coverage levels are particularly low (e.g. minorities and persons younger than 65 years Director of the of age with chronic underlying medical conditions). Increasing Division of Public routine, annual vaccination coverage levels in these groups will Health, KDHE further reduce the annual toll of influenza and will facilitate access to these populations when the pandemic occurs Enhance pneumococcal vaccination coverage levels in traditional high-risk groups to reduce the incidence and severity of secondary bacterial pneumonia Ensure vaccine distribution plans are coordinated with the bordering states of Missouri, Nebraska, Colorado, and Oklahoma, as well as the Kansas City Metro Area Medical Countermeasures Coordinator, KDHE- BCHS Attorney, KDHE Immunization Program Director, KDHE Continue to review, modify and exercise the SNS SOGs at the state level and mass dispensing SOGs at the local level Ensure that contingency plans have been considered for emergency distribution of unlicensed vaccines using emergency Investigational New Drug (IND) provisions Train and exercise state and community partners on the antiviral distribution plan Ensure that state laws continue to allow for important elements of vaccination plans Maintain the Kansas Immunization Registry to track vaccine and facilitate reminder notification to track the administration of two doses per person (if recommended) and to track adverse events Educate the medical community and the public regarding appropriate vaccine information during a pandemic event January 2015 Page 31

32 WHO Phases U.S. Government Stages CDC Interval PANDEMIC ALERT PERIOD Human infection(s) with a new subtype, but no human-to-human spread, or at most rare instances of spread to a close contact. Small cluster(s) with limited human-to-human transmission but spread is highly localized, suggesting that the virus is not well adapted to humans. Larger cluster(s) but human-to-human spread still localized, suggesting that the virus is becoming increasingly better adapted to humans, but may not yet be fully transmissible (substantial pandemic risk) New domestic animal outbreak in at-risk county Suspected human outbreak overseas Confirmed human outbreak overseas Investigation Recognition During WHO Phase 3, the U.S. Government may be at Stage 0 or Stage 1. The assumption for the actions detailed below is that the federal government has declared Stage 1. Community Resilience and Incident Management The KDHE Director of the Division of Public Health will meet with the PIPC to review major elements of the plan and assess and evaluate state and local levels of preparedness. Changes to the plan will be made as needed. Communication with the border states of Missouri, Oklahoma, Colorado, and Nebraska, as well as the Kansas City Metro Area, should be maintained. Internal operating guides will be reviewed and updated to ensure that staff members are available and contact information is current. Community Preparedness According to the Implementation Plan for the National Strategy for Pandemic Influenza, the federal government will be utilizing the National Response Framework as the primary mechanism for coordinating the federal response to a pandemic. Roles of key federal agencies are described in the implementation plan; the roles of the U.S. Department of Health and Human Services (HHS) and U.S. Department of Homeland Security (DHS) are repeated here. The U.S. Secretary of Health and Human Services will be responsible for the overall coordination of the public health and medical response during a pandemic, to include coordination of all federal medical support to communities; provision of guidance on infection control and treatment strategies to local, state and tribal entities, and the public; maintenance prioritization, and distribution of countermeasures in the SNS; ongoing epidemiologic assessment, modeling of the outbreak, and research into the influenza virus, novel countermeasures, and rapid diagnostics. The U.S. Secretary of Homeland Security will be responsible for coordination of the federal response as provided by the National Strategy for Pandemic Influenza (Strategy), the Homeland Security Act of 2002, and Homeland Security Presidential Directive #5, and will support the Secretary of Health and Human Services coordination of overall public health and medical emergency response efforts. The Secretary of Homeland Security will be responsible for January 2015 Page 32

33 coordination of the overall response to the pandemic, implementation of the policies that facilitate compliance with recommended social distancing measures, the provision of a common operating picture for all departments and agencies of the federal government, and ensuring the integrity of the nation s infrastructure, domestic security, and entry and exit screening for influenza at the borders. Emergency Operations Coordination KDHE will initiate ICS at Level 2 Watch in preparation for pandemic influenza response. When this occurs, Operations and Logistics Section staff will begin activities to verify that facilities listed in this plan are ready to start response operations. Finance and Administration staff will prepare to begin documenting expenses related to pandemic response. Notification of a possible biological emergency will be communicated to KDEM and a Liaison Officer will be requested. The KDHE Incident Commander will convene the PIPC and review the plan and corresponding SOGs. Initiate KDHE Emergency Operations Guidelines (EOG). Maintain ILI disease surveillance. Activate the Public Information and Communication (PIC) Plan. Begin vaccine and antiviral medication distribution (if available). Notify KDEM of the need for additional resources. Activate SOGs for operational priorities. Arrange for facilities (DOC, SNS, as needed) use. Document expenses of pandemic response. Community Resilience and Incident Management U.S. Government Stages 1 & 2 Director of the Convene the PIPC and the Pandemic Influenza Task Force to Division of Public review major elements of the plan and assess preparedness level Health, KDHE KDHE-PIPC Review and revise KDHE operating guides and procedures KDHE Operations and Logistics Section KDHE Epidemiology Branch including contact information Ensure that facilities are ready and available Maintain surveillance PIO, KDHE Activate PIC Plan KDHE Operations Begin antiviral and vaccine distribution (if available) Section Liaison Officer, Notify emergency management of response and needed support KDHE KDEM Provide a Liaison Officer to KDHE ICS January 2015 Page 33

34 Biosurveillance The CDC continuously monitors surveillance data reported nationally, and frequently communicates with public health colleagues around the world so that novel viruses are detected and investigated as quickly as possible. If Kansas is notified by CDC that a novel influenza virus has been identified, but efficient transmission of the virus from person-to-person is not yet established (that is, a novel virus alert), Kansas will enhance Interpandemic Period surveillance activities by: Increasing case detection among persons who recently traveled to the outbreak area and present with clinical illness possibly caused by influenza including pneumonia, acute respiratory distress syndrome or other severe respiratory illness. Appropriate specimens will be collected to diagnose influenza infection. In some situations, if the novel influenza virus is a highly pathogenic avian strain, such as with the 2004 H5N1 influenza virus in Asia, local hospital laboratories should not attempt viral isolation because of the risk that the strain could spread. Specimens will be sent to KHEL for sub-typing or to CDC for sub-typing and isolation. Influenza infection can be diagnosed locally using antigen detection, immunofluorescence, or PCR; see Appendix M. CDC will provide guidance appropriate to each specific novel virus alert. The BEPHI will work with local health departments to investigate early cases and clusters of suspect pandemic influenza identified through ILINet or passive surveillance. BEPHI will be responsible for forwarding case reports to the local health department, and for specifying which CDC form (e.g. the Pandemic Influenza Case Investigation Form, the Novel Human Influenza Case Report Form, or an alternative form suggested by the CDC) to use for case investigations, and for timely reporting. Local health departments will be responsible for collecting patient histories as rapidly as possible, and for immediately forwarding complete case investigation forms to KDHE via fax, secure (encrypted) , or Kansas electronic disease reporting system, EpiTrax. Reporting of early novel and pandemic influenza cases to CDC, likely via an online CDC case reporting system. Ensuring that all Interpandemic Period influenza surveillance activities are underway regardless of the time of year and that all participating laboratories and ILINet providers are reporting data to CDC each week. Sub-typing all influenza A viruses identified in clinical specimens and immediately reporting to CDC any influenza A viruses that cannot be sub-typed. CDC will provide instructions on the safe handling of a potential novel influenza virus. Obtaining reagents from CDC (as these become available) to detect and identify the novel strain. Reviewing contingency plans for further enhancement of influenza surveillance if efficient person-to-person transmission of the novel virus is confirmed. If efficient person-to-person transmission of a novel influenza virus is confirmed, the following additional surveillance enhancements will be made: Assessing the need to screen travelers arriving in the U.S. from affected countries. Investigating the epidemiology of all early cases either originating in the U.S. or that are imported into the country. January 2015 Page 34

35 At hospitals and emergency departments, increasing laboratory diagnosis of influenza, including use of rapid antigen detection tests, for persons with compatible clinical syndromes, particularly those who may have had recent exposure at the site of an outbreak. CDC will provide guidance to assist with triage of specimens for testing and for choosing which isolates to send to CDC. The completeness and timeliness of reports from all participating laboratories and ILINet providers will be assessed, and non-reporters will be contacted to improve their performance as necessary. The BEPHI will investigate outbreaks and increases in ILI cases, including those detected through the ILINet surveillance system and those reported through traditional passive surveillance. Biosurveillance U.S. Government Stage 1 & 2 Increase case detection among persons who recently traveled to the outbreak area and present with clinical illness possibly caused by influenza including pneumonia, acute respiratory distress syndrome or other severe respiratory illness Report early novel and pandemic influenza cases to CDC Monitor and institute recommendations from CDC for any additional surveillance activities that should be undertaken given the specific circumstances Review contingency plans for further enhancing influenza surveillance if efficient person-to-person transmission of the novel virus is confirmed Assess the need to screen travelers arriving in the U.S. from affected countries KDHE-BEPHI Investigate the epidemiology of all early cases either originating in the U.S. or imported into the country Investigate early cases and clusters of suspect pandemic influenza identified through ILINet or passive surveillance Forward case reports to the local health department, and specify which CDC form to use for case investigations and timely reporting Ensure that all Interpandemic Period influenza surveillance activities are underway regardless of the time of year and that all participating laboratories and ILINet providers are reporting data to CDC each week Investigate outbreaks and increases in ILIs Assess the completeness and timeliness of reports from all participating laboratories and ILINet providers and determine if improvement measures are necessary KDHE-KHEL Subtype novel viruses Subtype all influenza A viruses identified in clinical specimens and reporting any influenza A viruses that cannot be subtyped to CDC immediately January 2015 Page 35

36 Kansas hospitals Obtain reagents from CDC (as reagents become available) to detect and identify the novel strain At hospitals and emergency departments, increase laboratory diagnosis of influenza, including use of rapid antigen detection tests for persons with compatible clinical syndromes, particularly those who may have had recent exposure at the site of an outbreak Surge Management The PIPC will review this plan and the corresponding SOGs. Procedures and equipment in the KDHE Department Operations Center will be tested to ensure operational readiness. Medical Surge Healthcare system providers will review their emergency plans and procedures and ensure they are current and workable. Medical surge portions of the plan may be exercised and improvement plans will be developed and implemented. Isolation procedures will be reviewed and communicated to all staff. The importance of infection control procedures will be emphasized to staff, patients and visitors. The Planning Section within the KDHE ICS will monitor the Kansas Hospital Bed Availability (HAvBED) system. KDHE, in cooperation with the Kansas Hospital Association, will increase promoting use of this system by Kansas hospitals. Procedures for HAvBED use are in place and additional training will be made available to local hospital staff. Hospital bed availability, in concert with other situational data, will help planners at the local and state levels determine the need for additional care sites and supplies. Volunteer Management Additional training will be made available related to the Kansas System for the Early Registration of Volunteers (K-SERV). This system coordinates the deployment and tracking of volunteer medical and other professionals in an emergency and provides primary source verification for these professionals. The K-SERV system has been developed in accordance with the federal Emergency System for Advance Registration of Volunteer Health Professionals (ESAR-VHP) standards. Requests for additional volunteers will be coordinated through the local EOCs, like other requests for additional support. Local volunteer coordinators have access to K-SERV and will be able to utilize the system according to procedures already developed and disseminated. Surge Management U.S. Government Stages 1 & 2 Kansas hospitals Review emergency plans and procedures and ensure all facets are current and workable Exercise and improve medical surge portions of hospital emergency plans and corresponding procedures Inventory personal protective equipment and order additional supplies as identified Provide additional infection control procedure training to staff, patients, and visitors January 2015 Page 36

37 Planning and Outreach Specialist, KDHE-BCHS KDHE Planning Section Kansas Hospital Association KDHE-PIPC KDHE Logistics and Operations Sections Provide additional training opportunities for K-SERV for county volunteer coordinators Monitor Kansas HavBED system for bed availabilities in hospitals Promote the twice daily update of the Kansas HavBED system by hospitals Review Kansas Pandemic Influenza Preparedness and Response Plan and corresponding SOGs Review procedures and equipment in the KDHE Emergency Operations Procedures for operational readiness Information Management Once sustained human-to-human transmission is confirmed anywhere in the world, the Public Information staff will: Review major elements of the PIC Plan with partners and stakeholders. Disseminate information to public, partners and the media on an ongoing basis. Monitor media coverage and address misinformation. Coordinate with bordering jurisdictions. Emergency Public Information and Warning The KDHE Director of Communications serves as the Public Information Officer (PIO) under the KDHE ICS. The PIO and his or her staff maintain a system to effectively communicate with public health officials, healthcare professionals and other targeted audiences. This system is described in the KDHE PIC Plan and describes the following activities that would be conducted by the PIO and his or her staff: Review materials and revise as needed. Activate public hotline, if needed Disseminate information to public and partners on an ongoing basis. Educate public health officials, elected officials, community leaders, and the media about what information will and will not be available during a pandemic. Prepare spokespersons. Coordinate with bordering jurisdictions. Information Sharing Kansas Health Alert Network notifications will be sent to all appropriate state and local response partners informing them of preparedness activities. Information Management U.S. Government Stage 1 & 2 Director of Review materials and revise as needed Communications, Activate public hotline KDHE Disseminate information to public and partners on an ongoing basis January 2015 Page 37

38 Educate public health officials, elected officials, community leaders, and the media about what information will and will not be available during a pandemic Prepare spokespersons Coordinate communications plan with bordering jurisdictions Review major elements of the PIC plan with partners and stakeholders Monitor media coverage and address misinformation Coordinate with the Community Mitigation Branch regarding messages related to non-pharmaceutical interventions Respond to media requests for interviews as needed Countermeasures and Mitigation Plans and SOGs will be reviewed and updated with incident information including updated contact lists. Medical Countermeasure Dispensing Once human transmission is confirmed, local public health agencies will ensure that human resources and logistics are in place to begin vaccination, taking into account the need for additional staff due to illness and relief for workers. Just in time training should be implemented for relevant agencies and partner groups regarding vaccine delivery protocols and procedures. Activities will be coordinated with border states and the Kansas City Metro Area. Medical Materiel Management and Distribution Local and state health authorities will meet with appropriate partners and stakeholders and review major elements of SNS plans and SOGs. Plans will be modified to account for any updates on recommended target groups, projected vaccine supply and human resources. Once a novel virus has been identified, KDHE staff will review the distribution and priority prophylaxis and treatment plans to ensure they are updated. The medical community will be notified of the status of the plans and the availability of antiviral medications. KDHE will distribute guidelines to the medical community and conduct training for public health staff involved in antiviral distribution protocols and procedures. HHS will deploy the antiviral stockpile to state and tribal entities and to federal departments and agencies, along with prioritization and treatment recommendations. HHS will notify the Kansas SNS Coordinator to coordinate receipt. Non-Pharmaceutical Interventions Containment plans and SOGs will be reviewed and updated. State and local public health departments will continue to stress prevention messages and provide social distancing education to businesses, schools and community leaders. January 2015 Page 38

39 Responder Safety and Health All health and medical sector organizations will be advised of the importance of infection control as an overall mitigation strategy. Organizations should inventory personal protective equipment (PPE) and additional stocks may be ordered. Countermeasures and Mitigation U.S. Government Stage 1 & 2 Medical Meet with partners agencies and stakeholders to review state SNS Countermeasures plans and procedures Coordinator, KDHE- BCHS Local health Meet with partners agencies and stakeholders to review local mass departments dispensing plans and procedures KDHE-PIPC Recommend target groups based upon projected vaccine supply Director of the Division of Public Health, KDHE PIO, KDHE Local health departments and available resources Develop communications to the medical community convening the availability of antiviral medication and treatment protocols Develop and release stress prevention messages included in the social distancing education to target areas Provide Just-in-Time refresher training to volunteers and assisting agencies for vaccination campaigns January 2015 Page 39

40 WHO Phases U.S. Government Stages CDC Interval PANDEMIC PERIOD 6 Pandemic phase; increased and sustained transmission in general population. 3 Widespread human outbreaks in multiple locations overseas Recognition 4 First human case in North America Initiation 5 Spread throughout the United States Acceleration Peak Deceleration 6 Recovery and preparation for subsequent waves Resolution Community Resilience and Incident Management KDHE will activate ICS and organize incident management activities in the DOC. The KDHE Emergency Readiness Initiative would likely be activated which allows for the use of all KDHE staff to be available to assist with incident management and response activities. Emergency Operations Coordination KDHE has developed pandemic influenza triggers that delineate staffing and appropriate actions for various trigger points during the pandemic alert period. Those trigger points are as follows: 1. World Health Organization declares Pandemic Alert, U.S. Government moves to Stage 3 and identifies the Pandemic Severity Index (PSI) for the particular causative virus. HHS notifies SNS Coordinator that they will ship the federal cache of antiviral medications to Kansas. Kansas identifies itself as Interval Investigation. 2. The Kansas Receipt, Staging, and Storage (RSS) Warehouse is activated to receive assets. 3. The U.S. Government declares Stage 4 First Case identified in North America. Based on surveillance Kansas identifies itself as Interval Investigation/Unaffected state or as Interval Investigation/Affected depending on the probability or confirmation of disease in the state. 4. The U.S. Government declares Stage 5 Spread throughout the United States First case in Kansas. Actions based upon federal guidance for respective stage, PSI and respective intervals. a. Kansas asynchronously identifies affected geographic area as Interval Investigation/Affected area with concomitant actions surrounding the initiation element. Kansas continues to identify the rest of the state as Interval Investigation/Unaffected. b. Kansas detects secondary clusters and identifies as Interval Recognition. Kansas continues asynchronous local and regional interval designations. c. Kansas declares Mitigation Standby if PSI 1-3, and Alert if PSI 4-5 identifies as Interval Initiation/Acceleration as surveillance warrants. Kansas activates community mitigation interventions for affected communities. January 2015 Page 40

41 d. Kansas declares Peak Interval and extensive community transmission as indicated by one or more of the three guidance based criteria for the interval. PSI based actions taken in affected areas. 5. The U.S. Government declares Stage 6 Recovery and preparation for subsequent waves. a. Asynchronously within the state, evident signs of infection rate reductions become apparent and affected areas are identified as Interval Deceleration. b. As cases become more sporadic, interval designations of resolution are declared for areas and communities of the state where surveillance supports the identified interval. The complexity and variability of action surrounding the WHO phases, and the U.S. Government stages tied to the PSI and resulting intervals, will result in the development of operational decision algorithms. Appendix N represents a sample algorithm for use asynchronously within the state. It is based upon a WHO phase 4, U.S. Government-designated PSI 5 event, with resulting interval-based actions tied to state and local BIAs, resulting local SOGs and the Community Containment Tool Box and the school-based Pandemic Action Kit. These trigger points were used for deciding staffing of the KDHE ICS. Since the antiviral medication shipment will necessitate activating an RSS Warehouse, KDHE will activate the Departmental Operations Center and additionally staff the ICS. The KDA is responsible for all food safety programs in Kansas. Food safety has been identified as the number one priority for KDA in the event of any crisis that would affect the ability of the agency to carry out essential functions, which would include a pandemic. Personnel assigned to food safety responsibilities are located throughout the state and cross-training has occurred with all staff. These staff will be used in place of current staff if they are unavailable to provide inspections. Inspections will be conducted during all phases of a pandemic. All state-inspected slaughter/processing establishments will be directed to communicate problems and resource requests to their local EOCs. It is anticipated that many of these facilities will still contact their assigned inspector or the KDA directly, and that information will be shared with the local EOC. The ESF 11 coordinator in the SEOC will coordinate resource requests with other ESF Coordinators and the logistics personnel, as needed. Status of food producers will be maintained by the ESF 11 Coordinator and provided to the planning section in the SEOC as requested. Due to the large number of regulated facilities, only those experiencing problems will be included in the status reports. Facilities able to continue business as usual will not be tracked or reported on. It is unlikely that state-level response teams would be needed (or available) to carry out stateadministered nutritional assistance and agriculture emergency response support responsibilities during a pandemic. The nutritional assistance programs are managed by a handful of state-level managers on a day-to-day basis. The overwhelming majority of program implementation activity is done at the local level. School districts administer school nutrition programs, the local and state health departments manage the Women, Infants and Children (WIC) program, hundreds of nongovernmental entities implement commodities programs, and the Supplemental Nutrition January 2015 Page 41

42 Assistance Program is administered by the Kansas Department for Children and Families. If the local agencies have not prioritized these programs in their continuity of operations planning, there is little that can be done from the state level. As mentioned previously, the newly formed group will be working to develop some guidance, but there are few regulatory avenues that would be available to require local entities to administer these programs during a pandemic, with the exception of the Supplemental Nutrition Assistance Program. The state agency is required to accept and process applications, even in the event of a pandemic. Kansas Department for Children and Families (KDCF) field staff would carry out these functions with alternative methods as deemed necessary in a pandemic. Agriculture emergency response support would be provided the same way in a pandemic as it is for other disasters and emergencies in Kansas. Critical response activities are prioritized in all state agency COOPs. It is anticipated that state agencies will be able to provide very little additional support to local jurisdictions during a severe pandemic. Plans are being developed to ensure that essential public safety and public health programs can continue, even with a potential 50 percent reduction in staff. It would not be prudent to assume that resources above and beyond that would be available. The newly formed Nutritional Assistance Group is developing procedures for alternative approaches for carrying out state-administered nutritional assistance during a pandemic. The KDA will serve as the ESF 11 coordinating agency in the event of a pandemic. Nutritional assistance program status will be reported on a weekly basis to the ESF 11 desk in the SEOC. If there are problems or needs, program managers will also report these to the ESF 11 desk as they occur. In the event of an agriculture or animal disease emergency, the producers will notify their local EOC. Requests for assistance will be routed to the ESF 11 desk in the SEOC. The KDHE Incident Commander with the approval of the Secretary of KDHE may choose to advise the Governor through The Adjutant General of the State of Disaster Emergency for the influenza pandemic. If a State of Disaster Emergency is declared by the Governor a recommendation that all state government agencies implement their COOPs may be made. A major focus of these COOPs shall include limiting work hours to personnel who perform priority COOP functions. This limiting of state workers is expected to have the effect of limiting the disease spread among the workforce and be part of the state s overall layered disease mitigation strategy. In an effort to reduce and delay the spread of infection through the state workforce, the KDHE Incident Commander may recommend the implementation of COOP measures to the Governor s Office, through the Secretary of KDHE and The Adjutant General s Department, for all state agencies. The implementation of these measures may be dictated by the PSI and result in the reductions of state functions corresponding to that severity. When there is a COOP event, a significant disruption of state government or agency business operations then all affected agencies shall promptly: 1. Follow established notification and decision making procedures, as specified in the respective agency COOP. January 2015 Page 42

43 2. Notify the governor (or their designated representative) about the situation and extent of plan activation. 3. Notify KDEM, who will subsequently notify the appropriate county s office of emergency management The JIC will coordinate the release of this information with the Governor s Office to the citizens of Kansas. Community Recovery Recovery items related to the Pandemic Phase are addressed in U.S Government State 6: Community Recovery. Community Resilience and Incident Management U.S. Government Stages 3, 4 & 5 KDA Ensure all food producers, transporters, retailers, and consumers are aware of information and educational resources prior to, during, and after a pandemic Assist farm-to-fork operators with planning for the human resource challenges that may affect their businesses during a pandemic Serve as a source of information for stakeholders regarding state and local actions and resources available to producers during a pandemic Engage in vigorous continuity of operations planning to ensure that the department can continue to provide the services necessary to maintain the integrity and safety of the food supply KDHE Incident The KDHE Incident Commander will activate the KDHE Command Department Operations Center and fully activate the response plan The Planning Section Chief will monitor staffing needs and recruit additional staff, if necessary The Liaison Officer will ensure activities are coordinated with the bordering states of Missouri, Nebraska, Oklahoma and Colorado, as well as the Kansas City Metro Area The KDHE Incident Commander will ensure that CDC is briefed on the actions occurring in Kansas The Finance Section Chief will document the expenses related to responding to a pandemic influenza outbreak The Operations Section Chief will ensure coordination of BEPHI response activities with those of the local health departments and the medical community The KDHE Incident Commander, in coordination with the KDHE Secretary and The Adjutant General of Kansas, will determine when to advise the Governor to declare a State of Disaster Emergency in response to the influenza pandemic January 2015 Page 43

44 The KHEL will provide testing and technical support to the pandemic response, coordinate the response of the Kansas Laboratory Response Network, and provide guidance to clinical laboratories statewide The Planning Section Chief will monitor staffing needs at the KDHE Biosurveillance The Epidemiological Branch Director in the KDHE ICS will ensure that studies are in place to monitor vaccine effectiveness as well as assess the quality of surveillance and make recommendations for improvement during the period between pandemic waves and after the pandemic. In addition, the Epidemiological Branch will be responsible for tracking adverse events to vaccine and treatment. The Epidemiological Branch Director will also coordinate the monitoring of health impacts, including deaths and hospitalizations, from influenza. Public Health Surveillance and Epidemiological Investigation KDHE OVS has implemented an electronic death reporting system. Personnel within the OVS and BEPHI can access the system, and build queries regarding deaths from specific causes, such as influenza or pneumonia. In the event that the electronic death reporting system is not operational, influenza-associated deaths will be tabulated manually, using traditional, paperbased methods. During the early period of the pandemic, the Epidemiological Branch will use information gathered from local health departments case investigations, WebEOC, and the OVS electronic death reporting system to determine the disease s attack and case-fatality rates, the number and rate of pandemic-associated hospitalizations, the number of pandemic-associated deaths, and the numbers of newly isolated and quarantined citizens. Tabulated data may be transmitted to the CDC as requested. The Epidemiological Branch, with assistance from OVS, may utilize bridged estimates from the National Center for Health Statistics to calculate estimated rates of influenza-associated hospitalization. The Planning Section, in cooperation with the Kansas Division of Emergency Management, will measure absenteeism in key industries. The Kansas Division of Emergency Management, which regularly partners with key industries and critical infrastructure in Kansas, may reach out to the many organizations and sectors that may suffer from reduced workforces. Collecting information on the number of workers ill as well as possible impacts to critical business functions may help provide a more complete understanding of the disease s impact to Kansas communities. In the event of a suspect or confirmed case of pathogenic avian influenza, the Animal Health Commissioner will contact the State Epidemiologist or designee via the Epidemiology Hotline, in addition to contacting The Adjutant General s Department via . January 2015 Page 44

45 Public Health Laboratory Testing Studies have demonstrated a dramatic increase in antiviral medication resistance in some commonly circulating influenza strains to certain antiviral medications. The technology required to perform antiviral resistance testing is not available to most laboratories, including KHEL. In response, CDC has implemented an enhanced antiviral resistance testing and surveillance program. Each of the CDC Collaborating Laboratories is asked to submit a certain portion of influenza isolates to CDC. KHEL is participating in this surveillance program and will submit an increased number of specimens for antiviral resistance monitoring. Biosurveillance U.S. Government Stages 3, 4 & 5 KDHE Incident Recommend the implementation of COOPs to the Governor s Command Office through the Secretary of KDHE and The Adjutant General s Department for all state agencies KDHE-KHEL Assist CDC with monitoring for antiviral resistance KDHE Ensure that studies are in place to monitor vaccine effectiveness Epidemiological Coordinate monitoring of health impacts including deaths and Branch hospitalizations from influenza Determine the disease s attack and case-fatality rates Assess the quality of surveillance and make recommendations for improvement Track adverse events to vaccine and treatment KDHE Planning Section and Kansas Division of Emergency Management Measure absenteeism in key industries Surge Management KDHE will implement generic elements of the response plans and specific plans for identified pandemic influenza issues, including continuous collection of data concerning medical and material supplies and their allocation, in order to rapidly identify changing patterns of need and modify or redirect policy. Medical Surge Depending upon the severity of the pandemic, communities may choose to utilize alternate care facilities for patients presenting with symptoms of pandemic influenza. These alternate care sites may be utilized to facilitate congregate care of similarly symptomatic patients whom do not require intensive medical treatments. The use of these facilities by communities could prove effective in maintaining the hospital for those with severe complications or other non-pandemic related medical emergencies such as labor and delivery, traumas, and normal daily emergency room situations. The Disease Containment Branch will coordinate the provision of infection control measure messages to healthcare delivery personnel as well as the general public. KDHE will coordinate January 2015 Page 45

46 best practice recommendations from the CDC, HHS, and Association for Professionals in Infection Control and Epidemiology (APIC). This information will be shared via a variety of avenues including the JIC and KS-HAN, in partnership with the Kansas Hospital Association, the Kansas APIC chapters and the Kansas Board of Emergency Medical Services (KBEMS). The role of behavioral health professionals in pandemic response is important for the health of Kansans. Continuity of operations plans describe the reduction of services during this time. This reduction of services may have many effects to the employment status of Kansans. Behavioral health providers will have a role in drafting messages and providing services to established clients and the general population during this time. These messages may also address the expectation of deaths at places other than medical care facilities, depending on the severity of the pandemic. Once the pandemic is underway and healthcare providers rely on clinical criteria rapid test kits, more diagnostic activities may be conducted locally and fewer shipments may be needed. Public health laboratories should continue to build partnerships with healthcare providers in their jurisdictions, including physicians who participate in the ILINet during the regular influenza season. Fatality Management In the event of mass fatalities caused by pandemic influenza, it may be necessary to establish a virtual Family Assistance Center where information can be received and disseminated by means other than personal contact, in order to reduce potential exposure to virus. Additional information concerning the manner in which Kansas will address a mass fatality incident may be located in the Kansas Mass Fatality Plan attached to the Kansas Response Plan. Surge Management U.S. Government Stages 3, 4 & 5 KDHE Disease Provide infection control messages to healthcare personnel Containment Branch Coordinate best practice recommendations and share this information with the State JIC and local partners Kansas communities Activate and staff alternate care sites, if applicable Information Management Using the communication systems identified during the Interpandemic Period, public information staff will update appropriate agencies and the public at least weekly and as needed regarding any new information regarding the novel virus and its impact. Materials and messages will be reviewed and modified as needed with information from the CDC, HHS, and infection control specialists. Emergency Public Information and Warning When the SEOC is activated, the state JIC will also be activated. KDHE s PIO will serve with the JIC to ensure consistency of information from the State of Kansas. JIC activities will be coordinated with bordering states and the Kansas City Metro Region. In addition to the January 2015 Page 46

47 messages provided by KDHE, KDA will coordinate with the nutritional assistance program managers and advise the public regarding availability of nutritional assistance programs. In addition to the messages provided by KDHE, KDA will advise the public regarding food product recalls, safe food handling procedures, and any issues regarding shortages, substitutions, etc. Information Management KDHE public information staff may conduct scheduled conference calls with interested local health departments, hospitals, and other medical providers to increase information sharing and provide briefings prior to the release of pandemic influenza message campaigns. KDA will coordinate with partner agencies to ensure that all applicable nutrition assistance program information is provided to stakeholders during the Pandemic Period. KDA will assume the role as the ESF 11 coordinating agency during the pandemic response. A key component of this role is to coordinate the response to agricultural emergencies. KDA will continue to monitor the agriculture sector and provide necessary information and resources, if available, to ensure the continuity of food production in Kansas. KDA will ensure that all applicable food safety information is provided to stakeholders during the pandemic period. KDA will also communicate with agricultural producers and other regulated entities to help KDHE provide messages regarding disease containment in the workplace and updates on the status of the pandemic. Information Management U.S. Government Stages 3, 4 & 5 State JIC Provide updated information to appropriate agencies and the public at least weekly and as needed regarding virus and impact KDA Provide all applicable nutrition assistance program information to stakeholders Countermeasures and Mitigation The timely and appropriate application of mitigation activities and countermeasure strategies could have the effect of reducing the impact of the pandemic on Kansas. Medical Countermeasure Dispensing KDHE may activate the Department Operations Center and distribute vaccine and supplies necessary for influenza vaccine administration (e.g., needles and syringes) through a centralized distribution system to local health departments using SNS infrastructure or utilize the federal vaccine distribution system. Utilization of the federal vaccine distribution system in this instance will be preferable to better ensure the viability and stability of the vaccine. In addition, the federal vaccine distribution system already has mechanisms in place to maintain cold chain custody of the material. As part of ongoing pandemic influenza planning efforts, KDHE may work with vaccine distributors to develop a state-controlled distribution system. This system may be utilized in a situation where total vaccine distribution is the responsibility of the state or in a situation where distribution below a required threshold determined by the federal government is needed. In either instance, distribution of a specified number of doses of vaccine and medical supplies is based upon population and distribution of prioritized at-risk or essential January 2015 Page 47

48 services personnel and request of the county. Supplies to support vaccination efforts may be shipped separately from vaccine, depending on the availability of supplies. A state-controlled distribution of vaccine will be in-place during pandemic response. KDHE will focus distribution of vaccine and vaccine administration supplies to local health departments and hospitals within the state of Kansas. Utilizing vaccination rate data supplied by local health departments and hospitals to KDHE s Planning Section, KDHE will determine the appropriate time and manner to begin providing state-controlled vaccine to other health and medical sector partners including commercial pharmacies. This determination will include the adequacy of vaccine and supplies, hospital and health department pandemic response work load factors, and trends in vaccination rates. Medical Materiel Management and Distribution If needed, KDHE will consult with KDEM and SEOC staff to help coordinate the storage, security, and transportation of vaccine and supplies. As previously mentioned, this distribution effort may be in accordance to previously planned and exercised SNS infrastructure. It will be crucial to continue close coordination with local, state and federal partners. The Disease Containment Branch may also assist in the distribution of pneumococcal vaccine for high-risk individuals in the event of supply shortage. Those high-risk individuals will be identified and prioritized at the local level in much the same way as the influenza vaccine. The SNS infrastructure may be utilized for distributing these measures. Once the onset of a pandemic is confirmed, KDHE will fully activate the antiviral medication distribution plan. These medications will be provided to healthcare facilities for the treatment of pandemic influenza patients according to guidance and requirements set forth by the federal government. Non-Pharmaceutical Interventions Epidemiological Branch staff will monitor adverse reactions to influenza vaccine using the VAERS. This effort will be in coordination with the monitoring of infection and fatality rates associated with the virus. Epidemiological studies of cases, adverse reactions, trends, and effectiveness of containment measures will be conducted using standard epidemiological techniques and methodologies. This information will assist state planners and response staff in determining the effectiveness of the vaccine and the need for additional disease containment measures. To promote accurate epidemiological investigations at all levels of government, it is important for local health departments, hospitals, physicians, and other health and medical professionals to be alert for any reactions or trends and report them via VAERS. Responder Health and Safety In a severe pandemic, KDHE may implement vaccination of those state government officials and state and federal personnel deemed as priority for maintaining essential services. Utilizing similar methodologies as local jurisdictions, the State of Kansas will identify these personnel. Utilizing the medical staff available within the state government system, KDHE will coordinate the provision of vaccine to these individuals to promote continuity of government. January 2015 Page 48

49 Countermeasures and Mitigation U.S. Government Stages 3, 4 & 5 KDHE SNS and Distribute vaccine, supplies, antiviral medication, and other RSS Units medical supplies KDHE Monitor adverse reactions to influenza vaccine Epidemiological Branch KDHE Disease Assist in distribution of pneumococcal vaccine for high-risk Containment Branch individuals Local health and Report any adverse reactions to vaccinations or trends to VAERS medical professionals U.S. Government Stage 6: Community Recovery The State of Kansas utilizes the Homeland Security Exercise Evaluation Program (HSEEP) to evaluate response and recovery tasks associated with exercises and emergency incidents. Utilizing HSEEP, KDHE will work with appropriate partners at the state, local and federal level to develop improvement plans for the KDHE Department Operations Center, RSS Warehouse and SEOC based on the after action reviews for each of those venues. Specific modification of the response plans and operating guides or procedures will be implemented as needed. In addition to HSEEP evaluation methodology, epidemiological studies and reports will identify strengths and weaknesses of response measures, those particularly related to community disease containment, vaccination, and healthcare efforts. Food supply system assets will be assessed as needed. Inspections will be conducted on the same schedule as the Interpandemic Period, unless problems or issues are reported to KDA in accordance with current procedures. In the final stages of the pandemic, KDA will ensure that all applicable food safety, agriculture, and nutritional assistance information is provided to the public and regulated entities to continue the precautions identified in previous phases. It is important to recognize that a severe influenza pandemic will likely have a significant mental health effect on Kansas citizens, responders and government officials. During the times between pandemic waves, behavioral health professionals may be needed across all sectors of society to promote resiliency and provide crisis counseling and stress management opportunities for individuals. Considering the likely economic impact workers will face as a result of a severe pandemic, behavioral health providers will potentially be called upon by industry to assist with individuals being returned to work, or with workers displaced because of reductions in work load. State ESFs will continue activities into the recovery phase as outlined in the base Kansas Response Plan. Restoration of services for the health and medical community, including congregate living services, behavioral health, healthcare, public health, EMS, and laboratory services, will be coordinated by KDHE. The focus will be to get local communities back to Interpandemic Period capabilities as quickly and efficiently as possible. KDHE will work with licensure entities in Kansas to restore applicable levels of oversight to those disciplines. Within the KDHE ICS is a Health Recovery Branch, which promotes coordinated community January 2015 Page 49

50 restoration efforts by working with the KDHE Division of Public Health. Regulatory inspections of hospitals and other KDHE-regulated entities will resume as scheduled and defined in procedure. Recommendations concerning standards of care for both medical care and prehospital care arenas will continue to be revised and released as information related to infection and best practices becomes available. The SEOC will continue to monitor and coordinate with identified critical infrastructure and key assets. Recovery of these assets will promote recovery of the entire state. As assets begin to return to Interpandemic Period operations, the interaction with the SEOC will decrease. Community Recovery U.S. Government Stage 6 All responding Perform after action reviews and implement improvement plan organizations action items Regulating agencies Restoration of regulating activities to pre-pandemic schedule and procedure KDHE Coordination of restoration of health and medical services Continue to revise and release recommendation concerning standards of care SEOC Coordinate with critical resources and key assets to promote recovery and monitor degree of impact to operations POST PANDEMIC PERIOD When the pandemic has been declared over, local and state response will return to Interpandemic Period activities. Plan Development and Maintenance The Pandemic Influenza Planning Committee reviews lessons learned, after action reports, improvement plans and new pandemic planning guidance to further develop this plan. The Kansas Pandemic Influenza Preparedness and Response Plan is reviewed and updated during the fall of each calendar year. A revised plan is scheduled for release during the month of January of each year. January 2015 Page 50

51 Authorities and References State Legal Authority Statute Section Authority Disposition of Human Remains Health, Administration and Supervision Disposal of human remains during state of emergency relating to public health Articles 1 and 2 Duties of the Secretary of Health and Environment Public health system Local Health Officials Communicable Diseases and , 126, and Powers and duties of the department (KDHE) (Powers of the secretary) Powers and duties of the department as public health authority Local board of health; powers and duties Local health officer; qualifications and duties Powers and duties of department (given as powers of the secretary) Duties of local health officers Isolation and quarantine Communicable diseases; suspected cases; protection of the public (reporting suspected case) Investigation of Deaths Control of Communicable Diseases and 129 Violation of law relating to health Funeral for someone who dies of communicable disease Reports of communicable diseases (protection against liability and the necessity of reporting) Investigation and control of communicable diseases General statement of powers for control of communicable diseases January 2015 Page 51

52 Isolation and quarantine Disasters, responsibilities of the Governor, state of disaster emergency Issuance of proclamation of emergency January 2015 Page 52

53 Glossary Characterization DMORT Endemic Enzootic Epidemic Epizootic Health Alert Network Influenza-like illness (ILI) JIC Novel virus Pandemic PCR Strategic National Stockpile (SNS) Subtype Surveillance Syndromic Identification of the strain of an influenza virus such as A/Panama A coordinated effort of forensic experts and mortuary personnel to effectively handle a mass fatality disaster A disease that is continually present in a community or a region Affecting or peculiar to animals of a specific geographic area. The occurrence of a disease in a community or region clearly in excess of normal expectations Affecting a large number of animals at the same time within a particular region or geographic area. An Internet-based service used to communicate health and emergency messages The presence of fever >100 F, with a cough or sore throat A Joint Information Center is a central location for involved agencies to coordinate public information activities and a forum for news media representatives to receive disaster or emergency information A virus rarely or not previously known to infect humans The occurrence of a disease in excess of normal expectations in extensive regions, countries and continents Polymerase chain reaction is a laboratory method used to isolate and amplify a fragment or sequence of DNA. The technique allows for the rapid identification of organisms such as bacteria, fungi, and viruses. A federal cache of medical supplies and equipment to be used in emergency and disaster situations Identification of influenza A viruses according to the hemagglutinin (H) and neuraminidase (N) components of the virus, such as H1N1 or H3N2 The collection, analysis and dissemination of data Occurring as part of a complex of signs and symptoms suggesting the existence of an undesirable condition or disease January 2015 Page 53

54 Acronyms and Abbreviations ACIP BDCP BIA BCHS BEPHI CDC COOP DHS DMORT DOPH EIS EMT EOC EOP ESF FDA FEMA HAvBED HHS HSEEP IAL ICP ICS ILI IND JIC KBEMS KDA KDEM KDHE KHEL KS-HAN LHD LIN NIMS NREVSS NRF OIE OVS PCR Advisory Committee on Immunization Practices Bureau of Disease Control and Prevention Biological Incident Annex Bureau of Community Health Systems Bureau of Epidemiology and Public Health Informatics U.S. Centers for Disease Control and Prevention Continuity of Operations U.S. Department of Homeland Security Disaster Mortuary Operational Response Team Division of Public Health Epidemic Intelligence Service Emergency Medical Technician Emergency Operations Center Emergency Operations Plan Emergency Support Function U.S. Food and Drug Administration U.S. Federal Emergency Management Agency Kansas Hospital Bed Availability System U.S. Department of Health and Human Services Homeland Security Exercise Evaluation Program Incident Action Level Infection Control Professional Incident Command System Influenza-like illness Investigational New Drug Joint Information Center Kansas Board of Emergency Medical Services Kansas Department of Agriculture Kansas Division of Emergency Management Kansas Department of Health and Environment Kansas Health and Environmental Laboratories Kansas Health Alert Network Local Health Department Laboratory Information Network National Incident Management System National Respiratory and Enteric Virus Surveillance System National Response Framework World Organization for Animal Health Office of Vital Statistics Polymerase Chain Reaction January 2015 Page 54

55 PIC PIO PIPC PPE PSAP RSS RT-PCR SEOC SNS SOG USDA USG VAERS VIS VOAD WHO Public Information and Communication Public Information Officer Pandemic Influenza Preparedness Committee Personal Protective Equipment Public Safety Answering Point Receipt, Staging and Storage Real Time Polymerase Chain Reaction State Emergency Operations Center Strategic National Stockpile Standard Operating Guide U.S. Department of Agriculture United States Government Vaccine Adverse Events Reporting System Vaccine Information Statement Voluntary Organizations Active in Disasters World Health Organization January 2015 Page 55

56 Appendices Appendix A KDHE NIMS Position Title Crosswalk (First title listed is primary position; other position is the second shift/back-up) Incident Commander Political Liaison Officer Safety Officer Operations Section Chief Epidemiological Branch Director Laboratory Branch Director Planning Section Chief Logistics Section Chief Fin/Admin Section Chief Command Staff Dir Div of Health, KDHE Deputy Secretary, KDHE Senior Executive Policy Analyst, KDHE Dir Div. of Environment, KDHE KS TRAIN Administrator Deputy Incident Commander Departmental Liaison Officer Public Information Officer Workforce Development Coordinator Operations Section Staff Director of Homeland Security Operations, BCHS Disease Containment Branch Director Customer Support Manager, OTIS Deputy State Epidemiolgist, BEPHI RSS Branch Director Senior Epidemiologist, BEPHI KHEL Laboratory Director Mass Fatality Branch KHEL Health Section Director Chief Planning Section Staff STD Program Director, BDCP SNS Unit Leader Deputy Bureau Director, BHP Logistics Section Staff Office Manager, BCHS Communications Unit Public Service Leader Administrator 1, BCHS Finance/Administration Section Staff Director of Administration & Evaluation, BCHS Procurement Unit Leader Director of Grants Administration, BCHS State Epidemiologist, KDHE Administrator, Division of Public Health Director of Local Public Health, BCHS Health Facilities Program Director, BCHS Director, Office of Communications KDHE Public Information Officer, KDHE Immunization Program Director, BDCP TB Control Director, BDCP Director, Bureau of Environmental Health Deputy Director, BEPHI Executive Director, KFDA Disaster Coordinator, KFDA SNS Coordinator, BCHS Planning & Outreach Specialist, BCHS Planning & Technology Specialist, BCHS Response/Restoration Unit Manager, BER BCHS CAPS BEHCAPS January 2015 Page 56

57 Appendix B Public Health Emergency Activation Levels Public Health Emergency Activation Levels Level 1 Normal Operations Day-to-day operations ESS monitors surveillance system statewide Epidemiologist-on-call is notified of reportable diseases or unusual events Contact with the Epidemiologist-on-call is made 24/7 via the Epi Hotline ( ) Influenza surveillance coordinator gathers information on ILI activity in the state on a weekly basis Level 2 Watch Passive and sentinel surveillance indicates that an unusual event or outbreak has occurred and further case ascertainment is needed Active and enhanced surveillance initiated at the State and/or Local levels Decision makers are able to mobilize internal resources to identify and contain diseases KS-HAN notifications sent to appropriate health departments, physicians, hospitals, and sentinel sites Epidemiological investigation is conducted by state and local health department staff Law enforcement may be notified if the event has potential law enforcement implications Level 3 Response Emergency Public Health Response is necessary KDHE Department Operations Center is activated Limited outside resources needed Decision makers are able to mobilize internal resources to identify, contain, or mitigate the disease Public Information is handled through the KDHE Office of Communications Public Information Phone Bank may be activated Level 4 Full-Scale Activation Resources outside of Public Health and Medical agencies are needed State Emergency Operations Center is activated KDHE Department Operations Center is activated Kansas State Emergency Operations Center (SEOC) Team is notified and activated if necessary Biological Incident Annex or ESF #8 are activated Governor may issue a proclamation declaring a state of disaster emergency Kansas Pandemic Influenza Preparedness and Response Federal Plan resources Version may be requested (e.g. SNS, NDMS) January 2015 Joint Information Center is staffed and operational Page 57

58 Response Phases Appendix C Crosswalk of Activities I II Normal Watch Operations WHO Pandemic Phases US Government Phases Interpandemic Period Phase 1 & 2 Pandemic Alert Period Phase 3, 4 & 5 III Response Pandemic Alert Period Phase 5 IV Full-Scale Activation Pandemic Period Phase 6 V Recovery Post Pandemic Period USG Phase 0 USG Phase 1, 2 USG Phase 2, 3, 4 USG Phase 5 USG Phase 6 CDC Interval Investigation Investigation Recognition Planning and Coordination Situation Monitoring and Assessment (Disease Investigation) Health System Response Prevention and Containment (Vaccination/ Prophylaxis) (Quarantine/ Isolation) Communications Planning with state agencies and task forces. Training and exercising of plan Normal operation Review and revise hospital emergency operations plans. Train and exercise surge portions of plan. Community planning for alternate care sites. PIPC review and update the Vaccine and Antiviral Delivery section of the plan as needed Prepare and distribute Isolation and Quarantine Order Templates to LHD. Review and update PIC plan and the communications section of this plan Notify KDEM and other partners. Activate Plan. Broad dissemination of case definition for active case finding of novel virus in KS resident. Review applicable surge sections of plan. Revise as necessary with community partners Initiate vaccine and antiviral acquisition Advise hospitals and clinicians of control measures, including quarantine and isolation orders for novel virus cases. KDHE PIO will review PIC Plan with PIPC. Minimal or Extended Response. DOH Resources. DOC and activated to Level 3, request KDEM Liaison Case finding of pandemic strain in KS residents Activate Hospital Incident Command System (HICS) in affected healthcare facilities Continue to identify high-risk groups for possible treatment with antivirals and prepare for mass vaccination. Review community control measures. Consider group isolation measures. KDHE PIO conducts communication activities outlined in the plan. Initiation, Acceleration, Peak, Deceleration Ask for Governor s Declaration of Emergency Case investigation limited to determining agespecific attack rates, morbidity and mortality HICS continue to operate in hospitals. ESF 8 coordinates temporary facilities. Conduct mass immunizations when vaccine is available. Continue treatment with antivirals if available. Implement community control measures including group isolation. KDHE PIO conducts communication activities outlined in the PIC plan. Resolution Demobilization and conduct AAR. Epidemiological studies as outlined in the plan Return to normal case investigation. Continues until patient load normalizes and disease transmission is interrupted Assess the effectiveness of vaccine and antivirals. Review effectiveness of control. KDHE PIO reviews communication strategies used during the pandemic. January 2015 Page 58

59 Appendix D State Preparedness Committees Commission on Emergency Planning and Response Office of the State Fire Marshal Representative of: Kansas Department of Health and Environment: Counties Division of Environment Cities Kansas Department of Health and Environment: Businesses and Industries Division of Public Health Broadcasting Kansas Department of Transportation Agriculture, crop or livestock Kansas Highway Patrol Transportation, trucking or rail Kansas Adjutant General s Department Energy Kansas Department of Commerce Law enforcement officers Kansas Bureau of Investigation Fire fighters Kansas Department of Agriculture County emergency managers Emergency medical services Public works services hospitals Public health Tribes of Kansas individuals with disabilities Kansas Homeland Security Councils Clinical Resource Network (Specialties) Dermatology Infectious Disease Internal Medicine Pulmunology Family Medicine Toxicology Psychiatry Appendix E Coordination List COORDINATION OF PANDEMIC INFLUENZA PREPAREDNESS WITH STATE AND FEDERAL AGENCIES State Agencies Kansas Department of Health and Environment (KDHE) Kansas Department of Transportation (KDOT) Kansas Department of Aging and Disability Services (KDADS) The Kansas National Guard (KSNG) The Kansas Division of Emergency Management (KDEM) The Kansas Board of Emergency Medical Services (KBEMS) Kansas Department of Corrections (KDOC) Kansas Highway Patrol (KHP) Kansas Department of Agriculture (KDA) Divisions and bureaus within the Kansas Department of Health and Environment The Office of the Secretary January 2015 Page 59

60 The Division of Public Health The Kansas Health and Environmental Laboratories The Bureau of Epidemiology and Public Health Informatics (BEPHI) The Bureau of Disease Control and Prevention (BDCP) The Bureau of Family Health (BFH) The Bureau of Health Promotion (BHP) The Bureau of Community Health Systems (BCHS) Federal Agencies The Department of Health and Human Services (HHS) The Centers for Disease Control and Prevention (CDC) The Federal Emergency Management Agency (FEMA) The Food and Drug Administration (FDA) The Department of Homeland Security (DHS) The United States Department of Agriculture (USDA) Other Agencies Other State Health Departments Kansas Veterinary Diagnostic Laboratory Kansas Hospital Association Kansas Medical Society Salvation Army American Red Cross Kansas Association of Local Health Departments January 2015 Page 60

61 Appendix F Family (Home) Care for Symptomatic Individuals Home care will be the predominant mode of care for most people infected with influenza. During the Pandemic Alert Period, individuals should discuss with their healthcare provider specific recommendations for both vaccination and chemoprophylaxis. The single best way to prevent influenza is to get vaccinated each fall. In the absence of vaccine, however, there are other ways to protect against influenza. Only oseltamivir and zanamivir are currently recommended for seasonal influenza because of high levels of resistance to amantidine and rimantidine among currently circulating influenza A viruses. Adamantine (amantidine and rimantidine) have limited use in the prevention of influenza. Zanamivir is also used for chemoprphylaxis. All of these drugs are prescription drugs, and a doctor should be consulted before their use. The public should receive frequent and repetitive health communications that emphasize the simple steps that individuals and families may take to prevent the spread of respiratory illnesses like influenza: Avoid close contact with people who are sick. Wash hands often. If sick, stay at home and keep at least three feet away from others. Cover mouth and nose with a tissue when coughing or sneezing. Individuals who are cared for at home should: Get plenty of rest. Drink a lot of fluids. Avoid using alcohol and tobacco. Consider taking over-the-counter medications to relieve the symptoms of influenza (but never give aspirin to children or teenagers who have influenza-like symptoms). Stay home and avoid contact with other people. Cover nose and mouth with a tissue when you coughing or sneezing. In a pandemic influenza, some individuals who are cared for at home may develop complications. Should complications develop, these individuals should seek medical care immediately, either by calling the doctor or going to an emergency room. Upon arrival, the receptionist or nurse should be told about the symptoms so that precautions can be taken (providing a mask and or separate area for triage and evaluation). Warning signs to seek urgent medical care: In children, these include: High or prolonged fever Fast breathing or trouble breathing Bluish skin color Not drinking enough fluids Changes in mental status, somnolence, irritability Seizures Influenza-like symptoms improve but then return with fever and worse cough January 2015 Page 61

62 Worsening of underlying chronic medical conditions (for example, heart or lung disease, diabetes) In adults, these include: High or prolonged fever Difficulty breathing or shortness of breath Pain or pressure in the chest Near-fainting or fainting Confusion Severe or persistent vomiting January 2015 Page 62

63 Appendix G Internet Sites Referenced CDC FluAid FluAid is a test version of software created by programmers at the Centers for Disease Control and Prevention (CDC). It is designed to assist state and local level planners in preparing for the next influenza pandemic by providing estimates of potential impact specific to their locality. Kansas State Statutes (index) World Health Organization Pandemic Preparedness Kansas Response Plan (KRP) Mass Clinic (SNS) Standard Operating Guide Template for Local Health Departments Federal website with Pandemic Influenza planning tools and resources Valuable Links from pandemicflu.gov Antiviral Allocations for each state: State and Local Planning Checklist National Strategy for Pandemic Influenza: Implementation Plan January 2015 Page 63

64 Appendix H HHS Vaccine Priority Recommendations Table 2. Vaccination target groups, estimated populations, and tiers for severe, moderate and less severe pandemics as defined by the Pandemic Severity Index (PSI) Tier 1 Tier 2 Tier 3 Tier 4 Tier 5 Not targeted Category Homeland and national security Healthcare and community support services Critical infrastructure General population Target group Estimated number Deployed and mission critical pers. 700,000 Essential support & sustainment pers. 650,000 Intelligence services 150,000 Border protection personnel 100,000 National Guard personnel 500,000 Other domestic national security pers. 50,000 Other active duty & essential suppt. 1,500,000 Public health personnel 300,000 Inpatient healthcare providers 3,200,000 Outpatient and home health providers 2,000,000 Healthcare providers in LTCFs 800,000 Community suppt. & emergency mgt. 600,000 Other important healthcare personnel 500,000 Emergency Medical Service personnel 2,000,000 Law enforcement personnel Fire services personnel Mfrs of pandemic vaccine & antivirals 50,000 Key government leaders 50,000 Electricity sector personnel Natural gas personnel Communications personnel Water sector personnel Critical government personnel Transportation sector personnel Food and agriculture sector personnel Banking and finance personnel Pharmaceutical sector personnel Chemical sector personnel Oil sector personnel Postal and shipping personnel Other important government personnel 1,900,000 to 4,400,000 1,400,000 to 3,500,000 Pregnant women Infants & toddlers 6 35 mo old 3,100,000 10,300,000 Household contacts of infants < 6 mo Children 3 18 yrs with high risk cond. 4,300,000 6,500,000 Children 3 18 yrs without high risk 58,500,000 Persons with high risk cond. 36,000,000 Persons >65 yrs old 38,000,000 Healthy adults yrs old 121,800,000 Severe Moderate Less severe January 2015 Page 64

65 Figure 1. Vaccination tiers and target groups for a severe pandemic. This figure illustrates how vaccination is administered by tiers until the entire U.S. population has had the opportunity to be vaccinated, and how tiers integrate target groups across the four categories balancing vaccine allocation to occupationally defined groups and the general population. 300 M Rest of population High Risk Populations - High risk adults - Elderly 122 million Critical occupations - Military support - Border protection - National Guard Critical occupations - Intelligence services - Deployed forces - Other natl. security - Critical healthcare - Community services - EMS - Utilities - Fire - Communications - Police - Critical govt. - Govt. leaders High risk population High risk population - Infant contacts - Pregnant women - High risk children - Infants - Toddlers 17 million 23 million Critical occupations - Other active duty - Other healthcare - Other CI sectors - Other govt. High risk population - Healthy children 64 million 74 million Tier 1 Tier 2 Tier 3 Tier 4 Tier 5 Vaccination tier tiers January 2015 Page 65

66 Appendix I Local Pandemic Influenza Response Checklist ACTION Interpandemic Period Goals: Strengthen influenza pandemic preparedness, Minimize the risk of transmission to humans; detect and report such transmission rapidly if it occurs Establish a local healthcare task force as a focus for planning, preparedness and coordinated response. The task force should include representatives from hospitals, physician and nursing organizations, home healthcare, long-term care facilities, pharmacists, EMS and local public health officials. Develop strategies to increase the demand for influenza vaccine among your county s residents and especially healthcare workers. Continue to develop and refine the local Mass Dispensing, Community Disease Containment and Public Information and Communication SOGs. Work with the local chamber of commerce and large employers to increase awareness in the community. Conduct training and exercises to ensure the local Mass Dispensing, Community Disease Containment and Public Information and Communication SOGs are operational. Educate health department staff and healthcare providers about pandemic influenza. Estimate target populations (priority groups) of essential personnel, including healthcare workers, first responders and public safety workers. Pandemic Alert Period Goal: Ensure rapid characterization of the new virus subtype and early detection, notification and response to additional cases. Contain the new virus within limited foci or delay spread to gain time to implement preparedness measures, including vaccine development Maximize efforts to contain or delay spread, to possibly avert a pandemic, and to gain time to implement pandemic response measures Review Local Response Plan, Emergency Support Function 8 Health and Medical Annex. Review the Mass Dispensing, Community Disease Containment and Public Information and Communication SOGs, ensure contacts are updated and potential vaccination clinic facilities are available. Review local Point of Dispensing sites on Kansas Countermeasure Response Administration System and update, if necessary. Convene local health task force and brief on the status of the Pandemic Alert and local preparedness efforts. Review message maps relating to pandemic influenza and make sure they are current. Review priority group estimates. Ensure Mass Dispensing SOG addresses vaccine distribution to tribal entities, military installations, and correctional facilities, if applicable. Ensure city police departments and the county sheriff s offices are aware of the potential for civil unrest to occur in the event of a pandemic. January 2015 Page 66

67 Meet with adjoining jurisdictions to ensure actions will be coordinated in Phase 6. Special considerations include: priority group recommendations, vaccination clinic operations (hours of operation, locations, policies, and forms). Local health task force reviews the priority group recommendation of the KDHE and provides guidance to local health officer on any changes. Once priority groups are identified, estimate the number of local citizens in each group. Health department ensures that all agencies and volunteers tasked in the plan are aware of the Pandemic Alert Phase and the potential for escalation. Ensure all personnel who may have contact with the media are trained on the message maps. Ensure all media contacts are up to date. Log into WebEOC and familiarize staff with the system. Review security component of the Mass Dispensing SOG and ensure security assets are available and briefed. Pandemic Alert Period Goal: Minimize the impact of the pandemic Activate local Emergency Operations Plan (EOP), Emergency Support Function 8. Activate local Emergency Operations Center (EOC) and the local Joint Information Center (JIC). Administer influenza vaccine as it becomes available. Ensure a second dose of vaccine is administered if necessary. Assist KDHE with obtaining data to determine age-specific attack rates, morbidity and mortality. Work with KDHE to determine vaccine efficacy. Appendix J State Pandemic Influenza Checklist ACTION Interpandemic Period Goal: Strengthen influenza pandemic preparedness, Minimize the risk of transmission to humans; detect and report such transmission rapidly if it occurs Establish a state task force as a focus for planning, preparedness and coordinated response. The task force should include representatives from hospitals, physician and nursing organizations, home healthcare, longterm care facilities, pharmacists, EMS and local public health officials. Develop strategies to increase the demand for influenza vaccine among state residents; especially healthcare workers. Continue to develop and test the KDHE Internal Operating Guides. January 2015 Page 67

68 Ensure all KDHE Division of Public Health staff with response roles are trained on the National Incident Management system. (Complete IS-700 through KS TRAIN or provide certificate to training staff) Establish the Pandemic Influenza Preparedness Committee (PIPC) to draft and maintain the plan for a coordinated state response to an occurrence of pandemic influenza. Conduct exercises to test the state s ability to respond to large-scale outbreaks at least annually. Continue passive surveillance of influenza-like illness using the ILINet Surveillance System. KHEL will continue to isolate and sub-type influenza viruses year round. Continue to transmit information on influenza-like illness and influenza viruses isolated to CDC. Continue to conduct training and exercises to ensure the plan and corresponding SOGs are operational. Educate health department staff and healthcare providers about pandemic influenza. Estimate target populations (priority groups) of essential personnel, including healthcare workers, first responders and public safety workers. Continue to conduct laboratory and disease surveillance activities described in Phase 1. Pandemic Alert Period Goal: Ensure rapid characterization of the new virus subtype and early detection, notification and response to additional cases. Contain the new virus within limited foci or delay spread to gain time to implement preparedness measures, including vaccine development Maximize efforts to contain or delay spread, to possibly avert a pandemic, and to gain time to implement pandemic response measures Review the Kansas Response Plan to include: Emergency Support Function 8 Health and Medical Annex and the Biological Incident Annex. Review Mass Dispensing SOG, ensure contacts are updated and potential vaccination clinic facilities and state warehouses are available. Review local Point of Dispensing sites on Kansas Countermeasure Response Administration System and ensure local entities have updated, if necessary. Convene state health task force and brief on the status of the Pandemic Alert and local preparedness efforts. Review message maps relating to pandemic influenza and make sure they are current. Review priority group estimates. Make contact with state health departments in Missouri, Nebraska, Oklahoma and Colorado to update on status of planning and preparedness efforts. Ensure contact numbers are updated. Continue to conduct laboratory and disease surveillance activities described in Phase 1. Monitor and institute recommendations from CDC for any additional surveillance activities that should be undertaken given the specific circumstances. Ensure state law enforcement agencies (KBI and KHP) are aware of the potential for civil unrest to occur in the event of a pandemic. January 2015 Page 68

69 Test the functionality of the health and medical boards in WebEOC and update if needed. Ensure pandemic influenza information is available on the KDHE website. Activate public hotline if needed. Begin case detection among people who have recently traveled to the outbreak area and present with influenza-like illness or pneumonia. Continue disease surveillance activities described in Phase 1 regardless of the time of year. Meet with adjoining jurisdictions to ensure actions will be coordinated in Phase 6. Special considerations include: priority group recommendations, vaccination clinic operations (hours of operation, locations, policies, and forms). State health task force provides the priority group recommendation to the local health officers. KDHE collects information from the local agencies regarding the estimated numbers of people in the various priority groups. KDHE ensures that all agencies tasked in the plan are aware of the Pandemic Alert Phase and the potential for escalation. Ensure all personnel who may have contact with the media are trained on message maps. Ensure all media contacts are up to date. Log into WebEOC and familiarize staff with the system. Review security component of the Mass Dispensing SOG and ensure security assets are available and briefed. Educate public health officials, elected officials and the media about what information will and will not be available during a pandemic. Assess the need to screen travelers arriving in the U.S. from affected countries. Investigate the epidemiology of all early cases either originating in the U.S. or that are imported into the country. Recommend that hospitals and emergency departments increase laboratory testing of influenza, particularly those who may have had recent exposure at the site of an outbreak. The Bureau of Epidemiology & Public Health Informatics will investigate outbreaks and increases in ILIs. Pandemic Alert Period Phase 6 Goal: Minimize the impact of the pandemic Activate Kansas Response Plan (KRP), Biological Incident Annex. Activate State Emergency Operations Center (SEOC) and the Joint Information Center (JIC). Distribute or administer influenza vaccine as it becomes available. Ensure a second dose of vaccine is administered if necessary. January 2015 Page 69

70 Assist local health departments with data collection to determine age-specific attack rates, morbidity and mortality rates. Work with CDC to determine vaccine efficacy. Monitor health impacts of the pandemic including deaths and hospitalizations from influenza. Assess the quality of surveillance and make recommendations for improvement during the period between pandemic waves and after the pandemic. January 2015 Page 70

71 Appendix K Community Containment for Disease Tool Box The link provided directs the user to the Kansas Community Containment Standard Operating Guide template developed by KDHE, the Kansas Association of Local Health Departments, and the Kansas Association of Counties. Included on this website is a template Standard Operating Guide (SOG) for local health department and community use in planning for any disease outbreak, including pandemic influenza. Appendix L Diagnostic Assays during Pandemic Influenza Rapid Diagnostic Tests 1. Several rapid diagnostic test kits based on antigen detection are commercially available for Influenza. Laboratories in outpatient settings and hospitals can use these tests to detect Influenza viruses within 30 minutes. Some tests can detect influenza A viruses (including avian strains); others can detect influenza A and B viruses without distinguishing between them and some can distinguish between influenza A and B viruses. The type of specimens used in these tests (i.e., nasopharyngeal swabs, nasal swab, throat swab, or nasal aspirate,) may also vary. RT-PCR and rapid diagnostic tests do not require in vitro growth or isolation of virus. During a pandemic, rapid diagnostic tests will be widely used to distinguish influenza A from other respiratory illnesses. a. Biocontainment level: BSL-2 2. RT-PCR Subtyping a. Influenza specimens may also be typed and subtyped using real-time RT-PCR, which does not require in vitro growth or isolation of virus. CDC has trained scientists from all 50 states to use RT-PCR subtyping to identify human and avian HA subtypes of public health concern. These methods are in place for yearround surveillance of influenza-like-illness (ILI) and can be ramped up for surge capacity during an outbreak or pandemic event. Currently only nasopharyngeal and nasal swabs are accepted for testing with this method; additional specimen types may be added on an emergency use basis according to the discretion of the CDC. b. Biocontainment level: BSL-2 3. Virus Isolation a. Virus isolation growing the viral strain in cell culture for Influenza diagnostics is considered to be a best practice because it confirms that the virus is infectious. During a pandemic, virus isolation followed by antigenic and genetic (sequencing) analysis will be used to characterize the earliest pandemic isolates, as well as to monitor their evolution during the pandemic. Laboratories that participate in the WHO Global Influenza Surveillance Network typically use virus isolation followed by hemagglutination inhibition (HAI), IFA staining, or RT- PCR to monitor circulating seasonal strains of Influenza. If clinical and epidemiologic data suggest that a human case of influenza might be due to infection with avian influenza A (H5N1) or another highly pathogenic avian influenza strain (see Box 3), the virus should not be cultured except under BSL-3 January 2015 Page 71

72 conditions with enhancements. Laboratories that lack BSL-3 enhanced facilities may either perform RT-PCR subtyping using BSL-2 containment procedures or send the specimen to CDC for isolation and characterization. b. Biocontainment level: Inter-pandemic and Pandemic Alert Periods BSL-3 with enhancements; Pandemic Period BSL-2 c. KHEL does not perform these tests 4. Immunoflorescence Antibody Staining a. IFA staining following virus isolation can be used to identify influenza types (A, B) and influenza A HA subtypes using a panel of specific antisera. In some cases, IFA can be used for direct testing of cells pelleted from original clinical samples. CDC s Influenza Branch produces and distributes a reagent kit to WHOcollaborating laboratories that includes conjugated monoclonal antibodies for typing and subtyping currently circulating influenza viruses by IFA. Many laboratories use commercially available reagents to type influenza viruses by direct immunofluorescence tests (DFA). b. Immunofluorescence Assays Biocontainment level: BSL-2 when performed directly on clinical specimens; if used on cultures for earlier detection of virus, biocontainment recommendations for viral culture apply 5. Serological Tests a. Tests based on detection of antibodies in patient sera e.g., enzyme-linked immunosorbent assay (ELISA), HAI, and microneutralization assay can be used to retrospectively confirm influenza infection. Although microneutralization assay is the most comprehensive test for detection in humans of antibodies to avian influenza viruses, it is available in only a few state public health laboratories. b. Hemagglutination Inhibition (HAI) Biocontainment level: BSL-2 c. KHEL does not perform these tests. January 2015 Page 72

73 Appendix M Interval Sample Algorithm January 2015 Page 73

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78 Appendix N KDHE ILINet Sites January 2015 Page 78